super forms2

Your First Name
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Your Last Name
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Birth date
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Your Address
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Phone number
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Profession
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Sex
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Referral
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Reason for consulting
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Medical problems(select one or multiple)
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Surgeries
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Specify Surgery
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Family hereditary problems
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Specify Problem
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Medication
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If yes divided into 2 categories
Pain medication or medication related to your pain
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Medications related to your medical problem
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Did you perform any injection in your painful area before?
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Specify the injection
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Did you undergo a specific surgery in the area you are coming to consult for?
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Specify the surgery
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Did you undergo any trauma in the area you are coming to consult for?
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Specify
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Did you do physiotherapy or any kind of rehabilitation before?
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How many sessions
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What kind of rehabilitation
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Area or areas of pain (pick one or many)
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Others (please specify)
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Neck pain or Headaches

Does the pain wake you up at night?
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Is the pain is more acute in the morning?
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Please select the symptoms you are feeling to help us diagnose you better
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Can you specify your pain in a point?
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Specify pain
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Does your pain follows a specific trajectory?
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Specify trajectory
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Shoulder pain

Please select the symptoms you are feeling to help us diagnose you better
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Does the pain wake you up at night?
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Does the pain increase during work?
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Does the pain is more acute in the morning?
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Does the pain go away with any medication?
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Elbow pain

Does the pain wake you up at night?
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Does the pain affect your functionality?
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Do you have any impossible movement to do?
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Can you specify your pain in a point?
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Specify where
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Wrist pain

Can you lift things without having pain?
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Can you specify your pain in a point?
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Specify where
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Does your pain wake you up at night?
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Do you have any difficulty to move your fingers?
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Low back pain

Select one or multiple choice
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Is your pain more acute in the morning ?
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Does you pain increase while walking ?
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Does your pain go when you lay down on your back ?
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Do you have difficulty standing up from a chair ?
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Do you have flat feet ?
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Hip problem

Select one or multiple choice
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Does the pain increase on the stairs ?
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Do you have difficulty walking out the vehicle?
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Do you have difficulty while doing sports?
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Do you have difficulty waking up in the morning?
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Field is required!
Do you have flat feet ?
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Field is required!

Knee problem

Select one or multiple choice
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Do you have flat feet ?
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Field is required!