Date of Birth:
Primary Care Physician:
Right HandedLeft Handed
Chief Complaint: What is the reason for your visit today? Please include right, left, and bilateral (if applicable)
Was there an injury? YesNo
If Yes, date of injury:
Auto accident? YesNo
If Yes, State:
Timing/Context: How long do symptoms last? When do symptoms occur (time of day, after activities, etc.)?
Modifying factors: What makes the pain feel better? What makes the pain feel worse?
Associated signs/symptoms: Is there any swelling, redness, etc?
List any prior treatments and when/where performed (examples: surgery, braces, physical therapy, injections, medications):
Have you had any of the following studies previously? Mark if applicable and list when/where performed:
MRICT ScanEMG needle studyBone scanUltrasoundBlood workOther (explain)
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