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Briefly describe the issue you are experiencing

Has the patient had imaging pertaining to this problem (MRI, XRAY, CT SCAN etc)?YesNo

If yes, when?

What facility was imaging taken?

Has the patient had previous treatment related to this problem? (Chemo, radiation, or surgery, etc)YesNo

If so what?

Has the patient had previous surgery related to the problem above?YesNo

Has the patient been treated by another specialist for the described problem above?YesNo