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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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