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CONFIDENTIAL PATIENT HEALTH RECORD
Unwanted Condition (Why you are here today?)
When did this condition BEGIN?
Has this condition ever occurred
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Indicate the type and location of your sensations right now
Head
Neck
Shoulders
Arms
Hands
Chest
Stomach
Hips
Upper-back
Lower-Back
Front-Thighs
Back-Thighs
Knees
Calves
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Is the condition:
Auto Related
Job Related
Home Injury
Slip or Fall
Lifting
Slept Wrong
Unknown Cause
Other
Date of Accident
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Do you SUFFER with ANY other condition than which you are now consulting us?
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Body Balance Chiropractic & Wellness Center
Appointments and General Inquires: 281-890-5599
Address: 12155 Jones Rd, Suite A, Houston, TX 77070
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