AUTO/WORK RELATED ACCIDENT
Numb / Burning Feet Memory Loss. Slurred Speech Difficulty Swallowing. Vision Problems Dizziness. Tremor Poor Balance. Seizures Loss of Consciousness. Snoring Fall Asleep During the Day. Bladder Problems Depression / Anxiety. List your other medical problems (e.g., High Blood Pressure, Diabetes): (please turn over) ................
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