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State When Have you ever had an automobile accident No Yes When / Don t Remember Month Year Have you had a prior diagnostic imaging study or examination MRI or X-ray etc. in the last 2 years If yes please list None Body Part Month-Year MRI / Don t Remember X-Ray O A S I S C H I R O P R A C T I C D R. M Y L E S S T A R K M A N B R I C K E L L M I A M I C E N T E R F L P L A Z A 3 3 1 3 1 What are your present Complaints or Health Concerns Complaint / Concern 1 Pain or problem started on //...
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