CONFIDENTIAL PATIENT CASE HISTORY
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CURRENT HEALTH CONDITION
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PAST HEALTH HISTORY
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Indicate ability to perform the following activities:
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coughing or sneezing | |
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climbing | |
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getting in and out of a car | |
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kneeling | |
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bending forward to brush teeth | |
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balancing | |
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turing over in bed | |
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dressing self | |
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walking short distance | |
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sleeping | |
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standing more than one hour | |
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stooping | |
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sitting at table | |
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gripping | |
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lying on back | |
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pushing | |
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lying flat on stomach | |
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pulling | |
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lying on side with knees bent | |
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reaching | |
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bending over forward | |
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sexual activity | |
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For woman only
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Family History: |
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Accident Information
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If yes |
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in your own words please describe accident | |
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please complaints and symptoms | |
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