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MEDICAL HISTORY FOR PT

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In order for your therapist to best help you, please answer the following questions as best you can.

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Have you lost time from work?
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Please circle on the scale below your level of pain today. 0=No pain 10-= Pain that would make you go to the emergency room
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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