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Patient Intake and History Form. Date of Birth: *. American Indian or Alaskan Native. More Than One Race. Do you use a mail order. If so, please be sure we have your pharmacy provider information and a copy of your prescription drug card. REASON FOR COMING TO THE DOCTOR TODAY:. Reason for Today’s Visit:. When did symptoms first occur? Is this due to an accident? Describe the severity of the symptoms/pain. Associated Signs and Symptoms:. Are there any other symptoms associated with your problem? Has any m...

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