| Document Date: 2012-03-02 10:53:51
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City Arlington / / Company Full Motion Life & Sport PLLC / / IndustryTerm insurance / Car accident / / MedicalCondition miscarriages / numbness / pain / Y Polio Angina / allergies / Y Bladder trouble Gallstones / Headaches / pain in your neck / Y Alcoholism Tumor / diseases / Y Nervous breakdown Leukemia / Y Prostate problems Hypertension / exposure Heart Murmur Palpitations Rapid heartbeat Swollen extremities Cold extremities Chest pain / Y Paralysis Allergies / Y Gout Varicose veins / Y Parasites Mumps / Y Mental illness Cancer / Y Dysentery / neck pain / Y Kidney infections Hepatitis / Back pain / Y Hemorrhoids Phlebitis / Y Depression Blood disease / Muscle pain / / MedicalTreatment Contraception / / Person Headaches Injuries Bumps / Weakness Fatigue Fever Chills / Headaches Injuries Bumps Last / Weakness Fatigue Fever Chills Night / / / Position General / chiropractor / attending physician / Head / / ProvinceOrState Virginia / / Technology X-ray / MRI / /
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6013-B Wilson Blvd Arlington, VAPhone: Patient Case History Name: