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Test

    First:

    Last:

    Hand Dominance:

    Height:

    Weight:

    Hand Dominance:

    Who referred you to our clinic?:

    Do you see any other medical specialists (i.e., cardiologist, etc.)? If yes, please list:

    Pharmacy name and address:

    Date of injury:

    How did the injury occur:

    Where did the injury occur:

    Injury result of:

    If on the job, is it Workers' Comp? :

    Signature:

    Injury Location:

    What symptoms are you experiencing? :

    Pain Level (0-10; 10 being severe pain) :

    Have you ever had Physical Therapy for this issue? :

    What increases your pain? :

    Have you had chiropractic treatment? :