NAME, ADDRESS AND TELEPHONE NUMBER OF DOCTOR YOU ARE CURRENTLY TREATING WITH:

HOW OFTEN ARE YOU RECEIVING PHYSICAL THERAPY?

ARE YOU TREATING WITH ANY SPECIALIST?

IF SO, LIST NAME, ADDRESS AND TELEPHONE NUMBER OF SPECIALIST:

PRESENT COMPLAINTS:

DO YOU HAVE ANY TINGLING, NUMBNESS OR FALLING ASLEEP SENSATIONS IN YOUR ARMS OR LEGS?

ARE YOU SATISFIED WITH THE TREATMENT YOU ARE RECEIVING FROM YOUR DOCTOR?

HAVE YOU COMPLETED YOUR TREATMENT?

IF SO, WHEN WHERE YOU FORMALLY DISCHARGED?

DID YOU MISS TIME FROM WORK?

IF SO, LIST DATES YOU MISSED FROM WORK

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Signature Certificate

Document name: Treatment Status - Gilery Ogando

Unique Document ID: 826bdc40b54080351910a2a814477cc69069b3ad

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Timestamp	Audit
May 20, 2020 7:22 pm GMT	Treatment Status - Gilery Ogando Uploaded by David Rosenbaum - test@rosenbaumfirm.com IP 68.80.162.82
May 20, 2020 11:59 pm GMT	Gilery Ogando - gogando@rosenbaumfirm.com added by David Rosenbaum - test@rosenbaumfirm.com as a CC'd Recipient Ip: 68.80.162.82

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https://www.rosenbauminjuryfirm.com/

Audit Trail Serial# 78d6c7fb8d267494b06be0df1bcd121b