ࡱ> -/.ܥhW exY JJJJJJJJJJJJJ.JJX1KlpOpOpOpOpO RSUUUU/KUVwXXXYZXJT"pOpOTTXTJJpOKTTTT JpOJpOU6 JJJJJJTUT/T CHIEF Complaints or Symptoms: Name: Date: FORMCHECKBOX Neck pain check off the areas that the pain runs into from the neckFORMCHECKBOX none FORMCHECKBOX left shoulder FORMCHECKBOX left arm FORMCHECKBOX left forearm FORMCHECKBOX left hand FORMCHECKBOX right shoulder FORMCHECKBOX right arm FORMCHECKBOX right forearm FORMCHECKBOX right hand FORMCHECKBOX headacheFORMCHECKBOX Migraine Headache FORMCHECKBOX upper back pain Ringing in Ears FORMCHECKBOX Yes FORMCHECKBOX NoFORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Both Ears Blurry Vision FORMCHECKBOX Yes FORMCHECKBOX NoFORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Both EyesWrist Pain FORMCHECKBOX Yes FORMCHECKBOX NoFORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Both Wrists Jaw Pain FORMCHECKBOX Yes FORMCHECKBOX NoFORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Both Sides FORMCHECKBOX Dizziness FORMCHECKBOX nervousness FORMCHECKBOX fatigue FORMCHECKBOX anxiety FORMCHECKBOX depression FORMCHECKBOX excessive irritability FORMCHECKBOX fear of driving in a car FORMCHECKBOX a loss of concentration FORMCHECKBOX jaw clenching FORMCHECKBOX grinding of teeth at night FORMCHECKBOX nightmares FORMCHECKBOX difficulty with sleeping at night  FORMCHECKBOX Low Back Pain select the areas of radiation, if any... FORMCHECKBOX none FORMCHECKBOX buttocks FORMCHECKBOX left buttock FORMCHECKBOX left thigh FORMCHECKBOX left knee FORMCHECKBOX left foot FORMCHECKBOX right buttock FORMCHECKBOX right thigh FORMCHECKBOX right knee FORMCHECKBOX right foot  Hip Pain FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral Knee Pain FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral Foot Pain FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral Numbness: FORMCHECKBOX  Left Hand FORMCHECKBOX Left Upper Arm FORMCHECKBOX Right Hand FORMCHECKBOX Right Upper Arm FORMCHECKBOX  Left Foot FORMCHECKBOX Left Leg FORMCHECKBOX Right Foot FORMCHECKBOX Right Leg Additional Symptoms/ Complaints:  Have You lost any time from work due to your injuries? (Yes (No If yes please give dates: ____________________________________________________________________ Type of employment: _____________________________________________________________________________ Have you had previous injuries or accidents? (Yes ( No Description of previous Accident: ___________________________________________________________________ Description of previous injuries: ____________________________________________________________________ Is there any residual pain from the previous injury? (Yes (No How much better did you feel prior to your current condition? (Example 100%, 80% etc.) _________ /=Rn:LEGAL12npVALUE="Neck pain"r:npr_MS0nprselected VALUE="none"r:npr_MS1npr VALUE="left shoulder"n:npr_MS2npr VALUE="left arm"r:npr_MS3npr VALUE="left forearm"n:npr_MS4npr VALUE="left hand"v:npr_MS5npr VALUE="right shoulder"PEn:npr_MS6npr VALUE="right arm"r:npr_MS7npr VALUE="right forearm"r:npr_MS8npr VALUE="right hand"n:LEGAL13hpVALUE="Headache"n:LEGAL13hpVALUE="Headache"v:LEGAL15ubpVALUE="Upper back pain": ringing_RD0ringing"VALUE="Ringing in Ears was denied" WrapHtmlRadioJ: ringing_RD0ringing"VALUE="Ringing in Ears was denied" WrapHtmlRadioJ: ringing_RD1ringing'VALUE="Ringing sounds in the left ear." WrapHtmlRadio: ringing_RD2ringing(VALUE="Ringing sounds in the right ear." WrapHtmlRadio: ringing_RD3ringingVALUE="Ringing in the ears." WrapHtmlRadio: ringing_RD0ringing"VALUE="Ringing in Ears was denied" WrapHtmlRadioJ: ringing_RD0ringing"VALUE="Ringing in Ears was denied" WrapHtmlRadioJ:vis_RD1visVALUE="of the left eye" WrapHtmlRadio:vis_RD2visVALUE="of the right eye" WrapHtmlRadio~:vis_RD3visVALUE="of both eyes" WrapHtmlRadio: ringing_RD0ringing"VALUE="Ringing in Ears was denied" WrapHtmlRadioJ: ringing_RD0ringing"VALUE="Ringing in Ears was denied" WrapHtmlRadioJ: wrist_RD1wristVALUE="Left wrist pain" WrapHtmlRadio: wrist_RD2wristVALUE="Right wrist pain" WrapHtmlRadio: wrist_RD3wristVALUE="Bilateral wrist pain" WrapHtmlRadio: ringing_RD0ringing"VALUE="Ringing in Ears was denied" WrapHtmlRadioJ: ringing_RD0ringing"VALUE="Ringing in Ears was denied" WrapHtmlRadioJ: jaw_pain_RD1jaw_painVALUE="on the left" WrapHtmlRadio: jaw_pain_RD2jaw_painVALUE="on the right" WrapHtmlRadio: jaw_pain_RD3jaw_painVALUE="bilaterally" WrapHtmlRadio:more_symptoms_MS0 more_symptomsselected VALUE="none":more_symptoms_MS1 more_symptoms VALUE="nervousness":more_symptoms_MS2 more_symptoms VALUE="fatigue":more_symptoms_MS3 more_symptoms VALUE="anxiety":more_symptoms_MS4 more_symptoms VALUE="depression":more_symptoms_MS5 more_symptoms VALUE="excessive irritability"J:more_symptoms_MS6 more_symptoms! VALUE="fear of driving in a car":more_symptoms_MS7 more_symptoms VALUE="a loss of concentration":more_symptoms_MS8 more_symptoms VALUE="jaw clenching":more_symptoms_MS9 more_symptoms# VALUE="grinding of teeth at night":more_symptoms_MS10 more_symptoms VALUE="nightmares"t :more_symptoms_MS11 more_symptoms* VALUE="difficulty with sleeping at night"BHr:LEGAL16lbpVALUE="Low Back pain"v:lbpr_MS0lbprselected VALUE="none"r:lbpr_MS1lbpr VALUE="buttocks"v:lbpr_MS2lbpr VALUE="left buttock"r:lbpr_MS3lbpr VALUE="left thigh"r:lbpr_MS4lbpr VALUE="left knee"r:lbpr_MS5lbpr VALUE="left foot"v:lbpr_MS6lbpr VALUE="right buttock"r:lbpr_MS7lbpr VALUE="right thigh"r:lbpr_MS8lbpr VALUE="right knee"r:lbpr_MS9lbpr VALUE="right foot":hip_RD1hipVALUE="Pain in the left hip." WrapHtmlRadio:hip_RD2hipVALUE="Pain in the right hip." WrapHtmlRadio:hip_RD3hipVALUE="Pain in both hips." WrapHtmlRadio:knee_RD1kneeVALUE="Pain in the left knee." WrapHtmlRadio:knee_RD2kneeVALUE="Pain in the right knee." WrapHtmlRadio:knee_RD3kneeVALUE="Pain in both knees." WrapHtmlRadio:foot_RD1footVALUE="Pain in the left foot." WrapHtmlRadio:foot_RD2footVALUE="Pain in the right foot." WrapHtmlRadio:foot_RD3footVALUE="Pain in both feet." WrapHtmlRadio:knee_RD0kneeVALUE="Knee pain was denied" WrapHtmlRadio:knee_RD0kneeVALUE="Knee pain was denied" WrapHtmlRadio:knee_RD0kneeVALUE="Knee pain was denied" WrapHtmlRadio:knee_RD0kneeVALUE="Knee pain was denied" WrapHtmlRadio:knee_RD0kneeVALUE="Knee pain was denied" WrapHtmlRadio:knee_RD0kneeVALUE="Knee pain was denied" WrapHtmlRadio:knee_RD0kneeVALUE="Knee pain was denied" WrapHtmlRadio:knee_RD0kneeVALUE="Knee pain was denied" WrapHtmlRadioo name="fu_lbiceps" VALUE="+5">+5 cont234ABIT !"12?@AKLYZ[ijwxyuDC\^bGuDTC\^bGuDC\^bGuDlC\^bGuDC\^bGuDC\^bGuDC\^bGuDC\^bGuD0C\^bGuDC\^bGuDU8%*+89@CDQRY_`mnu|}uDC\^bGuD$C\^bGuDC\^bGuDC\^bGuD`C\^bGuDC\^bGuD,C\^bGuDC\^bGuDC\^bGuDC\^bGuDuD<C\^bG7 !./6MN[\chivw~*+289FGNUVcuDC\^bGuD@C\^bGuDC\^bGuDC\^bGuDC\^bGuDC\^bGuDtC\^bGuDC\^bGuDDC\^bGuDC\^bGuDuD@C\^bG7cdkxy  '(567QR_`az{uD%C\^bGuD@%C\^bGuD$C\^bGuD$C\^bGuD#C\^bGuD"C\^bGuDx"C\^bGuD!C\^bGuDl!C\^bGuD C\^bGuDuDX C\^bG7  ' ( / = g h u v w | }      ! " / 0 1 = uD4+C\^bGuD*C\^bGuDH*C\^bGuD)C\^bGuD`)C\^bGuD(C\^bGuDt(C\^bGuD'C\^bGUuD'C\^bGuD&C\^bGuDuD`&C\^bG6= > K L M X Y f g h      ! " / 0 7 O P ] ^ e k l y z uD0C\^bGuDd0C\^bGuD/C\^bGuDL/C\^bGuD.C\^bGuD0.C\^bGuD-C\^bGuD-C\^bGuD,C\^bGuD,C\^bGuD+C\^bGuD7   - . 5 E F S T [ g h u v } / 0 6 7 +,129:@A5uJUuDP5C\^bGuD4C\^bGuD84C\^bGuD3C\^bGuD 3C\^bGuD2C\^bGuD2C\^bGuD|1C\^bGuDc823C_| @AMp,p,p, V    p, w\   w\   w\   d %d  >+'M8Uvwx&   g t u v  ! B C N  w\   w\  p,*+*+*+p,;p,....d | j+d + d+ d %"N O k E ; 6E..p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,*p,p,p,*p,p,p,*p,p,l ,d | j+ K@Normala c*`* Heading 3,H3 <Uc"A@"Default Paragraph Font   c= 5 !MN "#$3BH!1@KZix$*9?CRX_nt| /5M\bhw}+18GMUdjx '6Q`z(.gv|!0=LXg!06O^dkz   . 4 E T Z g v | GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGLEGAL12npr_MSnpr_MS0npr_MS1npr_MS2npr_MS3npr_MS4npr_MS5npr_MS6npr_MS7npr_MS8LEGAL13LEGAL15 ringing_RD0 ringing_RD1 ringing_RD2 ringing_RD3vis_RD1vis_RD2vis_RD3 wrist_RD1 wrist_RD2 wrist_RD3 jaw_pain_RD1 jaw_pain_RD2 jaw_pain_RD3more_symptoms_MSmore_symptoms_MS0more_symptoms_MS1more_symptoms_MS2more_symptoms_MS3more_symptoms_MS4more_symptoms_MS5more_symptoms_MS6more_symptoms_MS7more_symptoms_MS8more_symptoms_MS9more_symptoms_MS10more_symptoms_MS11LEGAL16lbpr_MSlbpr_MS0lbpr_MS1lbpr_MS2lbpr_MS3lbpr_MS4lbpr_MS5lbpr_MS6lbpr_MS7lbpr_MS8lbpr_MS9hip_RD1hip_RD2hip_RD3knee_RD1knee_RD2knee_RD3foot_RD1foot_RD2foot_RD3@>XvPl-)Ebx 4^&gt.Je.\x  & !"#$%'2()*+,-./013456789:;I"A[y%Yu62Nk7a/w1Mhs7e / Joe Garolis D:\WINWORD\paterson\symptoms.doc@HP DeskJet 660CLPT1:HPFDJC04HP DeskJet 660CHP DeskJet 660C6d,,HP DeskJet 660CLPT1 ,,HP DeskJet 660C6d,,HP DeskJet 660CLPT1 ,,   1Times New Roman Symbol &Arial"ho )"Z0CHIEF Complaints or Symptoms: Name: Date: Joe Garolis Joe GarolisRoot EntryI;I4IIgI_1 windowsW F@6  I- 5DOCWordDocumentkemv.doc~PmP0GD:\WINWORD\patersonocLIEN_VOL.DOCبG.&2R!0Yo.doCompObjGG! ltrhead.docLTRHEAD.DOبG2lasher.docXFLASHER.j InSummaryInformationocEXAM. ( =164789:;<>?@ABCDEFGHI ܥhW eY JJJJJJJJJ6JJJJ.$KJY1:KlOOOOO?R#TPURURURU/UWX5YXYZX9JU"OOUUX!UJJO:KDocumentSummaryInformation8 yRoot EntryI;I4IIgI_1 windowsW F@6  I- 5DOCWordDocumentkemv.doc~PmP0GD:\WINWORD\patersonocLIEN_VOL.DOCبG.&2R!xYo.doCompObjGG! ltrhead.docLTRHEAD.DOبG2lasher.docXFLASHER.j InSummaryInformationocEXAM. (  !"#$%&'()*+,14Microsoft Word for Windows 95@G@@b4 @)  ࡱ՜.+,0HP\dl t|  v 1CHIEF Complaints or Symptoms: Name: Date: FMicrosoft Word Document MSWordDocWord.Document.69qࡱOh+'0( <H p |  1CHIEF Complaints or Symptoms: Name: Date:C Joe GarolisE Normal.dot Joe Garolis2!U!U!UU JOJOPU I- JJJJJJUPU!U/!U CHIEF Complaints or Symptoms: Name: Date: FORMCHECKBOX Neck pain check off the areas that the pain runs into from the neckFORMCHECKBOX none FORMCHECKBOX left shoulder FORMCHECKBOX left arm FORMCHECKBOX left forearm FORMCHECKBOX left hand FORMCHECKBOX right shoulder FORMCHECKBOX right arm FORMCHECKBOX right forearm FORMCHECKBOX right hand FORMCHECKBOX headacheFORMCHECKBOX Migraine Headache FORMCHECKBOX upper back pain Ringing in Ears FORMCHECKBOX Yes FORMCHECKBOX NoFORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Both Ears Blurry Vision FORMCHECKBOX Yes FORMCHECKBOX NoFORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Both EyesWrist Pain FORMCHECKBOX Yes FORMCHECKBOX NoFORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Both Wrists Jaw Pain FORMCHECKBOX Yes FORMCHECKBOX NoFORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Both Sides FORMCHECKBOX Dizziness FORMCHECKBOX nervousness FORMCHECKBOX fatigue FORMCHECKBOX anxiety FORMCHECKBOX depression FORMCHECKBOX excessive irritability FORMCHECKBOX fear of driving in a car FORMCHECKBOX a loss of concentration FORMCHECKBOX jaw clenching FORMCHECKBOX grinding of teeth at night FORMCHECKBOX nightmares FORMCHECKBOX difficulty with sleeping at night  FORMCHECKBOX Low Back Pain select the areas of radiation, if any... FORMCHECKBOX none FORMCHECKBOX buttocks FORMCHECKBOX left buttock FORMCHECKBOX left thigh FORMCHECKBOX left knee FORMCHECKBOX left foot FORMCHECKBOX right buttock FORMCHECKBOX right thigh FORMCHECKBOX right knee FORMCHECKBOX right foot  Hip Pain FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral Knee Pain FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral Foot Pain FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral Numbness: FORMCHECKBOX  Left Hand FORMCHECKBOX Left Upper Arm FORMCHECKBOX Right Hand FORMCHECKBOX Right Upper Arm FORMCHECKBOX  Left Foot FORMCHECKBOX Left Leg FORMCHECKBOX Right Foot FORMCHECKBOX Right Leg Additional Symptoms/ Complaints:  Have You lost any time from work due to your injuries? (Yes (No If yes please give dates: ____________________________________________________________________ Type of employment: _____________________________________________________________________________ Have you had previous injuries or accidents? (Yes ( No Description of previous Accident: ___________________________________________________________________ Description of previous injuries: ____________________________________________________________________ Is there any residual pain from the previous injury? (Yes (No How much better did you feel prior to your current condition? (Example 100%, 80% etc.) _________ /=Rn:= > K L M X Y f g h      ! " / 0 7 O P ] ^ e k l y z uD0C\^bGuDd0C\^bGuD/C\^bGuDL/C\^bGuD.C\^bGuD0.C\^bGuD-C\^bGuD-C\^bGuD,C\^bGuD,C\^bGuD+C\^bGuD7   - . 5 E F S T [ g h u v } / 0 6 7 +,129:@A5uJUuDP5C\^bGuD4C\^bGuD84C\^bGuD3C\^bGuD 3C\^bGuD2C\^bGuD2C\^bGuD|1C\^bGuDc823C_| @AMp,p,p, V    p, w\   w\   w\   d %d  >+'M8Uvwx&   g t u v  ! B C N  w\   w\  p,*+*+*+p,;p,....d | j+d + d+ d %"N O k E ; 6E..p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,p,*p,p,p,*p,p,p,*p,p,l ,d | j+ K@Normala c*@* Heading 3,H3 <Uc"A@"Default Paragraph Font     p,p,p,p,p,c= 5 !MN "#$3BH!1@KZix$*9?CRX_nt| /5M\bhw}+18GMUdjx '6Q`z(.gv|!0=LXg!06O^dkz   . 4 E T Z g v |  GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGLEGAL12npr_MSnpr_MS0npr_MS1npr_MS2npr_MS3npr_MS4npr_MS5npr_MS6npr_MS7npr_MS8LEGAL13LEGAL15 ringing_RD0 ringing_RD1 ringing_RD2 ringing_RD3vis_RD1vis_RD2vis_RD3 wrist_RD1 wrist_RD2 wrist_RD3 jaw_pain_RD1 jaw_pain_RD2 jaw_pain_RD3more_symptoms_MSmore_symptoms_MS0more_symptoms_MS1more_symptoms_MS2more_symptoms_MS3more_symptoms_MS4more_symptoms_MS5more_symptoms_MS6more_symptoms_MS7more_symptoms_MS8more_symptoms_MS9more_symptoms_MS10more_symptoms_MS11LEGAL16lbpr_MSlbpr_MS0lbpr_MS1lbpr_MS2lbpr_MS3lbpr_MS4lbpr_MS5lbpr_MS6lbpr_MS7lbpr_MS8lbpr_MS9hip_RD1hip_RD2hip_RD3knee_RD1knee_RD2knee_RD3foot_RD1foot_RD2foot_RD3@>XvPl-)Ebx 4^&gt.Je.\x  & !"#$%'2()*+,-./013456789:;I"A[y%Yu62Nk7a/w1Mhs7e  / Joe Garolis D:\WINWORD\paterson\symptoms.doc@HP DeskJet 660CLPT1:HPFDJC04HP DeskJet 660CHP DeskJet 660C6d,,HP DeskJet 660CLPT1 ,,HP DeskJet 660C6d,,HP DeskJet 660CLPT1 ,,   4   @@ 0@ @1Times New Roman Symbol &Arial"h )"Z0CHIEF Complaints or Symptoms: Name: Date: Joe Garolis Joe GarolisDf