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Reason for Visit
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Routine Follow Up
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Continued Treatment
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New Problem
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Additional Information
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Medical Events since last visit
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Surgical Events since last visit
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ER visits since last visit
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Hospital visits since last visit
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New MD’s since last visit
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Medication changes since last visit
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Weight changes since last visit
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Physical Exam
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General Appearance
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Additional Information
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Vital Signs
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Blood Pressure
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Heart Rate
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SP02 on Room Air
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SP02 on O2
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Temperature
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Hair: Normal
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If abnormal, enter additional information
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Scalp: Normal
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If abnormal, enter additional information
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Skull: Normal
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If abnormal, enter additional information
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Eyes: Normal
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If abnormal, enter additional information
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Ears: Normal
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If abnormal, enter additional information
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Nose: Normal
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If abnormal, enter additional information
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Throat: Normal
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If abnormal, enter additional information
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Neck: Normal
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If abnormal, enter additional information
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Thyroid: Normal
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If abnormal, enter additional information
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Supracla: Normal
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If abnormal, enter additional information
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Chest: Normal
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If abnormal, enter additional information
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Heart: Normal
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If abnormal, enter additional information
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Abdomen: Normal
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If abnormal, enter additional information
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Flanks: Normal
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If abnormal, enter additional information
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Upper Extremity: Normal
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If abnormal, enter additional information
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Lower Extremity: Normal
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If abnormal, enter additional information
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Skin: Normal
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If abnormal, enter additional information
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Neuro: Normal
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If abnormal, enter additional information
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Subjective Assessment
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Objective Assessment
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Pertinent Test Results
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Diagnosis
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Plan
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