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    Full Name:

    Today's Date:

    Please indicate anything that applies.

    Respiratory

    Notes:

    Head/Neck

    Notes:

    Cardiovascular

    Notes:

    Neurological

    Notes:

    Injury/MVA

    Type:

    Date:

    Current Symptoms:

    Pregnancy


    If Pregnant, how many weeks?:

    Cancer


    If Yes, what type?:

     

    Skin

    Notes:

    Digestive

    Notes:

    Psychological

    Notes:

    Surgery
    Type:

    Date:

    Current Symptoms:

    Allergies


    If yes, what type?:

    Arthritis


    If yes, what type?:
    Location:

    STI


    If yes, what type?:

    Anything not addressed:


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