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Susan Underwood Physical Therapy Patient Health Questionnaire Name DOB / / Age Occupation Height Weight Referred by whom Patient Client Staff Therapist Initials Are you aware of your diagnosis Yes No If yes what is it Please indicate if you have or have ever had any of the following PLEASE CIRCLE ONE What is your primary concern Back Neck Shoulder Arm Hand Hip Knee Ankle Foot Core strengthening Balance issues Headache Fibromyalgia Pelvic Floor Women s health Other Have you seen a physician...
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01
To fill out your name, provide your full legal name in the specified field.
02
To fill out your dob (date of birth), enter the date using the specified format (e.g., DD/MM/YYYY).
03
To fill out your age, subtract your date of birth from the current date and enter the result in years.
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What is name dob age?
Name, date of birth, and age are personal information that identifies an individual.
Who is required to file name dob age?
Anyone who needs to provide their personal information for official purposes may be required to file name, dob, and age.
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You can fill out name, dob, and age on a form provided by the requesting entity, ensuring that the information is accurate and up-to-date.
What is the purpose of name dob age?
The purpose of providing name, dob, and age is to accurately identify individuals, verify their identity, and ensure proper record-keeping.
What information must be reported on name dob age?
Name, date of birth, and age must be accurately reported to ensure that the individual's identity is correctly identified.
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