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CONFIDENTIAL PATIENT INFORMATIONPatient Name: First: ___ Last: ___ Date of Birth: ___Gender: ___Occupation: ___ Email: ___ Address: ___ ___ Home Phone: ___Cell Phone: ___Emergency Contact Person:

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Obtain the ugh pain ampamp spine form from the medical provider or online.

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Fill out your personal information including name, date of birth, and contact information.

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Provide details about your medical history and any previous injuries or conditions related to pain and spine issues.

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Describe the current symptoms you are experiencing including the location, severity, and duration of the pain.

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Patients who have had previous injuries or conditions that may be impacting their pain and spine health.

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Anyone experiencing symptoms such as back pain, neck pain, or other discomfort in the spine area.

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