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Pain Description & Medical History Form

Please complete this form to help us understand your current symptoms and medical background. Your responses will assist our team in providing the most effective and personalized care for your needs.

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Medical History
Please check all that apply.
Pain Location Please list the areas where you are having pain. Example: arm, neck, leg, shoulder, buttocks, etc.Describe whether the pain is upper area, lower, front or back. For example: upper arm in the front; lower leg by the ankle, etc.
Type of Pain (Select and/or describe the type of pain you are experiencing.)

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