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Steven Sampson, D.O. Danielle Aufiero, M.D. Mary A. Ambach, M.D. NONSURGICAL ORTHOPAEDICS AND SPORTS MEDICINEName:___ HEALTH QUESTIONNAIRETodays Date://Age:___PLEASE FILL OUT THIS FORM AS COMPLETE

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Today's date is October 24, 2023.

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Individuals or entities required to file tax returns must submit their information by the designated deadline.

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The purpose is to report financial information to the government for tax assessment purposes.

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