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Get OR DAS-RM 2012

Uture treatment expected? Yes No 31. If yes, explain:   32. Do you have any prior injuries to the injured body part(s)? Yes No 33. If yes, explain:   34. Do you have any other health issues (such as diabetes, arthritis, etc)? Yes No 35. If yes, explain:   36. Any other information you would like to provide to us:   Page 2 of 3 Revised 11/02/12 Form No. DAS-RM Standard form   Risk Management | EGS 1225 Ferry Street SE, U150 Salem, OR 97301 503-373-7475.

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