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PATIENT INTAKE FORM

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Was there a specific injury?
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Are your current symptoms work-related?
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Are you able to keep performing your job?
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If not, are you able to perform modified duty?
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Are your current symptoms the result of an accident?
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Road traffic accident?
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Boating accident?
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Is there litigation pending related to this injury?
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Please describe your symptoms by checking all that apply:
Do your symptoms wake you up at night?
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If you are having shoulder symptoms, please check all that apply:
If you are having hand, wrist, or elbow symptoms, please check all that apply:
Loss of feeling in fingers
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