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NF English (cont.)

DG Pain Management

Patient Health History - Intake Form (cont.)

Pain Management Injections
Back Surgery

Diagnostic Testing

Have You Had an MRI taken?

History

Please list all other medications you are currently taking:

Occupational History

Are you currently working?
Does your pain affect your ability to perform your job?

History and Physical

Sex:
Allergies Required
Medications Required
Are you on blood thinners? Required
Patient Medical History Required
Surgical History Required
Smoking Required
Alcohol Required
Drugs Required

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