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Name: PATIENTQUESTIONNAIREADULT DOB: Date: Referred from: Age: Height: Weight(lbs): Sex:Male/Female CHIEFCOMPLAINT/HISTORYOFILLNESS: 1. Whatisthereasonfortodaysvisit? 2. Haveyousoughtlegaladviceforthisproblem?yes
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To fill out weight, enter your weight in pounds. For instance, if you weigh 150 pounds, enter 150 lbs.
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