Fillable Chart Intake Pain Diagram pub 98 version WEB DOWNLOAD05-13-2010pub

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3425 Peach Street Erie, PA 16508 Phone (814) 8644100 Fax (814) 8661811 www.activecareerie.com SIGNATURE: Describe the problem(s) for which you are seeking treatment today: DATE: AGE: What date approximately did the problem begin? OR gradual onset since Describe how it happened: What activity, position or movement makes the problem(s) feel WORSE: What activity, position or movement makes the problem(s) feel BETTER:...
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