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Name: Primary Care Physician: Date of Birth: Referring Physician: Have you had physical therapy during this calendar year? Yes Have you had occupational therapy during this calendar year? No Yes No
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First, gather all the necessary information such as your medical history and any relevant documentation.
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Start by providing accurate personal details such as your name, date of birth, and contact information.
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Next, specify the purpose of the physical examination, whether it is for employment, sports participation, or general check-up.
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Answer the questions truthfully and thoroughly, providing details about any past medical conditions, surgeries, or allergies.
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If applicable, provide information about ongoing medications or treatments you are currently undergoing.
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