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In what region of the body is your pain and please briefly describe your symptoms? *

When and how did it occur? *

What aggravates it and what relieves it? *

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Are you taking medication for anything? If so, please briefly describe. *

I understand and agree that the advice that will be given to me is only intended as a possible indication of my pain/ injury and that an accurate clinical diagnosis will only be made from a full exam. *

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