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In your own words, what is (are) your specific concern(s)?
How bad is your pain the last 24 hours?
Present/Past Medical History:
Please check all that apply:
Orthopedic/Neurologic Surgeries, Fractures (last 10 years)
Other Past Surgeries
Hospitalizations other than surgeries (last 10 years)
(includes non-prescription products)
Frequency (times per day, as needed, etc.)
Pertinent Family Medical History
(cancer, heart, disease, hypertension, etc):