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Same Condition as Last?
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New Condition
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Exacerbation
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Overall VAS
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Date of Onset
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Caused by...
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Cause
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Improving
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Complaining of
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Other Symptoms
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Sharp Pain
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Dull Aching Area
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Stiffness/Soreness Area
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Mid Back Pain
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Neck Pain
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Headache
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Lower Back Pain
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UE Radiation
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LE Radiation
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Difficult ADLs
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Improved ADLs
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No Bowel/Bladder
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No Radiation
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No Trauma
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Free Write
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Fixation Area
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Fixation Levels
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Costal Vertebral Fix.
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Tenderness
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Upper Extremity Fixation
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LE Fixation
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Tone 1+
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Tone 2+
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Tone 3+
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Tone 4+
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Supine Short Leg
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Prone Check
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Functional Assessment
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Posture
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Computer Posture Eval
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Free Write
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Mild CROM Limit
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Mod CROM limit
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Severe CROM limit
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Pain
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Mild LROM loss
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Moderate LROM Loss
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Severe LROM loss
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Pain
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Free Write
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Assessments
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Diagnosis
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Supportive Care
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In Balance Category
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Free Write
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Maintenance
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CMT
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Cervical-Thoracic Prone
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Cervical Drop
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CMT C/Sp Bilateral
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Adj C-sp Rt only
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Prone Thoracic
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Adj C-sp Lt only
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Supine Thoracic
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Side Posture R only
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Side Posture Bilateral L/P
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Side Posture L only
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Light Force Cervical
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UE CMT
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L/P Drop
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LE CMT
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Pelvic Block
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Free Write
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Other Modality
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Modalities
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Active Release - Lower Extremity
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ARP Wave Stim
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Active Release - Spine
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Active Release - UE
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KTape
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Active Release - Shoudler
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Home Rec.
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Open Rehab
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Referrals
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Free Write
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Patient Responded
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Continue as Planned
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Time
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Radiology Orders
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Return
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