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Patient's Name
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Doctor's Name
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Occupation/Hobbies
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Diagnosis
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Patient's Age
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History
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Body Diagram
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Pain/Edema
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ROM: Neck flexion
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Neck rotation LEFT
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Neck rotation RIGHT
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Neck Sidebending LEFT
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Neck sidebending RIGHT
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Trunk flexion
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Trunk sidebending LEFT
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Trunk sidebending RIGHT
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Trunk rotation LEFT
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Trunk rotation RIGHT
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MMT
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Distraction
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Compression
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Posture
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Palpation (tone and tenderness)
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Special Test 1
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Special Test 2
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Special Test 3
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Special Test 4
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Special Test 5
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Problem 1
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Problem 2
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Problem 3
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Problem 4
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Problem 5
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Goal 1
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Goal 2
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Goal 3
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Goal 4
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Goal 5
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Rehab Potential
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Treatment Plan 1
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Treatment 2
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Treatment 3
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Treatment 4
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Duration to Achieve Goals
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Today's Treatment
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Provider
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