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Patient History

Patient History

Yes
No
Suddenly
Gradually
Only during activity
Sometimes at rest
All of the time
Sleep Well
Frequent Difficulty
Occasional Difficulty
Always Have Insomnia
Refreshed
Tired
Stiffer than usual
1
2
3
4
5
6
7
8+
Firm
Soft
Temper Pedic
Sleep Number
Water Bed
Other
X-Rays
MRI
EMG
CAT Scan
Bone Scan
Blood Tests
Other
None
Heart
Lungs
Kidneys
Digestive System
Infection
High Blood Pressure
Thyroid
Cancer
Other
Regular
Occasional
Never
Right Handed
Left Handed
Use Both
Yes
No
Yes
No
Married
Single
Seperated
Divorced
Other
Spouse/Partner
Friend
Children
Family Member
Alone
Pets
Happy
Relaxed
Satisfied
Enthusiastic
Sad
Anxious
Worried
Depressed
Receiving Workers Comp
I have applied for benefits
I have a lawsuit pending
Settlement or other benefits
No benefits pending
Other
None
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