• PATIENT INFORMATION UPDATE

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  • UPDATED PATIENT HISTORY

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  • Absent Uncomfortable Agonizing
  • 6. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)


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  • To the best of my ability, the information I have provided is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.

  • Clear
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  • Should be Empty: