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Page 1: 11. Did complaints BEFORE THE ACCIDENT? ( 12. Please ... · 14. Do you have any congenital (from birth) factors which relate to this problem? ( ) Yes ( ) No If yest please describe:
Page 2: 11. Did complaints BEFORE THE ACCIDENT? ( 12. Please ... · 14. Do you have any congenital (from birth) factors which relate to this problem? ( ) Yes ( ) No If yest please describe:

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