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T#): STATE: (ESTADO): SEX: MALE FEMALE (MASCULINO/FEMENINA): AGE: (EDAD): HOME PHONE: (TELEFONO DEL HOGAR): ZIP CODE: (CODIGO POSTAL): WORK PHONE: (TELEFONO DEL EMPLEO): EMPLOYER: (EMPLEADOR): DATE OF BIRTH: (FECHA DE NACIMIENTO: OCCUPATION: (OCUPACION): WERE YOU INJURED AT WORK? (FUE LASTIMADO EN EL TRABAJO?): YES (SI) (NO) (NO) REASON FOR VISIT: (RAZON POR LA VISTA): DATE OF INJURY: (FECHA DEL ACCIDENTE?): REFFERED BY: (REFERIDO POR): PRIMARY CARE PHYSICIAN: (NOMBRE.

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