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PATIENT INJURY MEDICAL HISTORY FORM

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Mark the treatments you have had for your problem:


Mark the treatments you have had for your problem:

List the types of Diagnostic Testing that have been performed for this problem.


List the types of Diagnostic Testing that have been performed for this problem.

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Do you have a PACEMAKER?
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Are you taking blood thinners?
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Mark any of the following that you have a family history of:
List your daily intake of:
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Functional Rating Index


Functional Rating Index

Pain Intensity
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Sleeping
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Personal Care ( Washing, dressing, etc)
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Travel (driving, etc)
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Work
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Recreation
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Frequency of Pain
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Lifting
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Walking
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Standing
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NOTICE OF HIPAA AND PRIVACY PRACTICES: This office protects your privacy as well as optimize your quality of care through access to your healthcare data. As part of your privacy, we will never share your information with a third party for marketing purposes. However, HIPAA guidelines allow sharing of general information for statistical reasons, such as a government health department or official third party. Your information may be used within this office or practice or with other healthcare professionals for training and educational purposes pursuant to HIPAA guidelines
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