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CC#1:
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CC#2:
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CC#3:
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CHIEF COMPLAINTS: CC#1: Pain _____/10
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CC#2: Pain _____/10
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CC#3: Pain _____/10
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SUBJECTIVE: Patient reports
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Symptoms
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Comments
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Activities
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Comments
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Home Care
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Comments
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OBJECTIVE
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Subluxation levels: C/S:____
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T/S:____
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L/S:____
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SI
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ExSpinal
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ASSESSMENT
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Additional Assessment
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Phase of Care
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Progress
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PLAN
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C/S:____
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T/S:____
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L/S:____
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SI
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ExtraSpinal Adjust
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Therapeutic Exercise: Areas___
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If Other, please mention
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Time____
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Description
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Additional Plan/Goals:______
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Please select
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Change plan next visit
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