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* Are you the primary policy holder?
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Employment Information


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Symptom Information


What date did your symptoms begin?
Have you ever had these symptoms before?
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No
How did this happen?
Is this injury work or auto accident related?
Yes
No
Are your arms or legs involved?
Yes
No
Please describe your chief complaint:
What makes it feel better?
What makesWhat makes it feel worse? it feel worse?
Please list all the medications prescribed to you within the last year
What kind of activities do you participate in during your free time?
Have you ever had or are you having problems with any of the following?
Headaches
Dizziness
Sinus Pain
Neck Pain
Upper Back Pain
Mid-Back Pain
Low Back Pain
Shoulder Pain
Chest Pain
Heart
Stomach
Bladder
Liver
Kidney
Colon
Hip
Circulation
Prostate
Breast
Have you ever been in an accident?
Yes
No
Have you ever been hospitalized or had any surgery?
Yes
No
Have you ever had measles, mumps, rheumatic fever, sexually transmitted disease or any other type of infection?
Yes
No
Have you or your family ever had cancer?
Yes
No
Have you or a family member ever been diagnosed with diabetes?
Yes
No
Has any family member ever had neck, back, or spinal problems?
Yes
No
Do you drink alcohol, smoke cigarettes, or ever use any recreational drugs?
Yes
No
If female, any possibility of currently being pregnant?
Yes
No

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