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  • Patient Information

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  • Employment Information

  • Insurance Information

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  • Describe Your Symptoms

  • Numbness

    10 being the worst
  • Burning

    10 being the worst
  • Stabbing

    10 being the worst
  • Tingling

    10 being the worst
  • Dull Ache

    10 being the worst
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  • Recent Symptoms/Pain

  • My pain interferes with Daily Activities

    Choose the effect of the current condition of your ability to perform the following tasks
    Check the one that best describes your job describes your job description.
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  • Physical Status

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  • Date Format: MM slash DD slash YYYY
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