Existing Patient Form

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Since you were last seen in our office, have you had any changes to your overall health? If so, what?

Describe your present symptoms

When did your symptoms start?

How did your symptoms begin?

Have you had similar symptoms in the past? If yes, please explain.

Have you had a recent fall? If yes, please explain.

Have you had recent surgery? If yes, please explain.

Have you recently been in an accident? If yes, please explain.

Anything else you want the doctors to know?

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