RAND 36 Item Health Survey

HOGAN CHIROPRACTIC SERVICES

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Patient Name: __________________________ Date: ___________ 1 of 4

RAND 36-Item Short Form Health Survey

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4 of 4 (Circle one number on each line)

Have you taken this survey through this office before? —–——————————- NO ————–— YES ————— IF YES - Have you had a new injury or illness since your last survey? ————— NO —————- YES —————Date of onset: ________________ Details of illness or injury: ___________________________________________ _________________________________________________________________________________