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Date
Allergies:
Why has your doctor sent you for this exam? Did he/she give you a specific diagnosis?
Please describe what specific complaints/symptoms have been most bothersome to you?
How long have you had these complaints/symptoms?
Do you have pain?
Yes
No
Did these complaints/symptoms come on sudden or gradually?
These complaints/symptoms have:
improved
remained the same
worsened
Have you had any previously surgeries related to today's exam?
Yes
No
If yes, type and date:
Have you had any prior tests related to today's exam?
MRI
Date
CT Scan
Date
Ultrasound
Date
Nuclear Medicine
Date
Other
Date
What were the results of these test?
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