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Confidential Patient Case History Dear Patient: Please complete this questionnaire. Your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactor
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Document Date: 2014-09-17 21:49:39


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MedicalCondition

allergy / Alcoholism Anemia Appendicitis Arteriosclerosis Arthritis Cancer Chorea / numbness / Pain / nerve disorder / Boils / Nervousness/depression Neuralgia Numbness Sweats Tremors MUSCLE / Varicose veins GENITO-URINARY / Chronic cough / Chest pain / emotional disorders / Eye pain / backache / Pus / Hives / Lumbago Neck pain / Kidney infection / Heart disease Influenza Lumbago Malaria Measles / Sore throat Tonsillitis / rash / such disorders / Cramps / stomach Poor appetite Vomiting Vomiting / Itching / /

MedicalTreatment

chiropractic / Birth control / surgery / /

Person

Allergy Chills / /

Position

General / /

Technology

X- ray / X-ray / /

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