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Get and Sign Occfit Solutions Form
Number:
Fax Number:
Please check all that applies below:
____
____
____
____
____
____
____
Edema or Swelling
Foot Tenderness or Discomfort
History of DVT
Varicose Veins
Tarsal Pain - Toes
Neuropathy
Shin Splints
Please check all that applies below:
____ Stand for prolonged periods of time while working
____ Sits for prolonged periods of time while working
____ Wears steel-toed or composite toed boots
____
____
____
____
____
____
____
Heel Pain
Plantar Pain
Ankle Pain
Knee Pain
Lower Back...
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