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PATIENT REGISTRATION
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* Indicates required question
Email
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NAME
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STREET ADDRESS
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CITY
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STATE
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ZIP
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EMAIL
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PHONE
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ALT. PHONE
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OCCUPATION
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EMPLOYER
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INSURANCE COMPANY
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OTHER
CASH
STAFF N/C
Other:
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PRIMARY COMPLAINT
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HOW DID THIS CONDITION DEVELOP?( WHAT CAUSED THIS)
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SELECT
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OVEREXERTION
STRENUOUS POSITION
AUTO ACCIDENT
WORK ACCIDENT
FALL
TRIP
Other:
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WHEN WAS THE FIRST TIME( DATE) YOU WERE AWARE OF IT?
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HOW WOULD YOU DESCRIBE THE SYMPTOMS?
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DULL ACHE
SHARP
STABBING
THROBBING
Other:
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HOW LONG DO THE SYMPTOMS LAST?
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INTERMITTANT
OCCASIONAL
FREQUENT
CONSTANT
WHAT AGGRAVATES THE PROBLEM?
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COUGHING
SNEEZING
LIFTING
BENDING
DRIVING
RIDING
PROLONGED SITTING
WALKING
STANDING
LYING
Option 11
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HAVE YOU HAD THE SAME OR SIMLILAR PROBLEM BEFORE?
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YES
NO
IF YES, EXPLAIN
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HAVE YOU EVER HAD MEDICAL TREATMENT FOR THIS CONDITION?
YES
NO
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BY WHOM?
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WHEN?
MM
/
DD
/
YYYY
GENERAL HEALTH
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EXCELLENT
GOOD
FAIR
POOR
IF POOR, EXPLAIN
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SURGERY:
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SELECT
MAJOR ACCIDENTS OR FALLS
BROKEN BONES
ALCOHOL
TOBACCO
ALLERGIES
DRUGS AND MEDICATIONS
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HOSPITALIZATION DATES
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REASON
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EXERCISE
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LOW
1
2
3
4
5
HIGH
TYPE OF EXERCISE
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DIFFICULTIES
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DIET
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EXCELLENT
GOOD
FAIR
POOR
IF POOR , EXPLAIN
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FAMILY HISTORY
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FEMALES: ARE YOU PREGNANT
YES
NO
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IF YES, HOW LONG
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ARE YOU NURSING?
YES
NO
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ADDITIONAL HISTORY, DOCTOR NOTES
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