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NAME: REFERRING PHYSICIAN: FAMILY PHYSICIAN:DATE: DATE OF BIRTH:MEDICAL HISTORY Is your current condition related to an injury? If YES, was the injury related to: Auto Work Yes Other No Are there
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What is is your current condition?
Your current condition is an assessment of your health or situation at the present moment.
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Individuals or organizations may be required to file a current condition report, depending on the specific requirements set forth by the governing body or organization.
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