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Approximate speed of your car mph Other car mph 8. Were you knocked unconscious 9. Were police notified If yes for how long 10. Do you notice any activity restrictions as a result of this injury 23. Other pertinent information DATE C-106 Reorder H. Have you lost t ime from work as a result of this accident If yes please complete this question. a. LastDayWorked b. Since this injury occurred are your symptoms Improving Getting Worse 20. CHECK SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT D...
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