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Chief Complaint/History of Present Illness
In your own words, what is (are) your specific concern(s)?
Rate the pain (Please circle: 0= no pain; 10=most severe)
What activites/medications help your condition?
What previous treatments have you had for this problem?
Please check any of the following that you have had:
Other serious health conditions:
Please list any previous surgeries you have had:
Please list all medications you are currently taking:
Frequency (times per day, as needed, etc.)
Has or does anyone in your family have any of the following?
Is there anything else we should know about you?