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EVALUATION FORM

  
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Injury Description
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Were you injured in Florida?
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Please describe your injuries:
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Additional Questions
Were you transported to the ER?
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Have you been seen by any other doctors since the accident?
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Do you suffer from any pre-existing conditions?
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Have you had a positive MRI or CT-Scan as a result of your accident?
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Has your work or pay been affected by your injuries?
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If you were in an automobile accident, did the other party have insurance?
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If you were in an automobile accident, do you have uninsured motorist coverage?
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