Injury Questionnaire
Valley Spine & Sport
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Name and Age:
Your answer
Describe your main complaint(s) and symptoms.
Your answer
Describe HOW and WHEN your symptoms began.
Your answer
List any important medical or injury history.
Your answer
What makes the symptoms better?
Your answer
What makes the symptoms worse?
Your answer
Have you seen any other health care professionals for this condition.
If yes, who did you see and what tests (X rays, MRIs, etc) and treatments were provided?
Your answer
Rate your level of function with 100% being normal.
Your answer
What are you looking to do that you are currently unable to do because of these symptoms.
Your answer
Any other questions, concerns or comments?
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