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Patient referred by
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Patient referral comments (add)
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Situation
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Reason for today's visit
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Reason for Visit Comments (add)
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Since last appointment
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Since Last Appointment Comments (add)
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Patient complaints
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Patient Complaint Comments (add)
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* Symptom location
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Symptom location (add)
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Symptom location specifics (level)
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Symptom location specifics (add)
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* Symptom quality
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Symptom quality/description (add)
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* Associated symptoms
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Associated symptoms comments (add)
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Symptom onset
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Symptom onset comment (add)
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Symptom trend
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Symptom trend comment (add)
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* Modifying factors
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Modifying factors comments (add)
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Bowel/bladder
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Bowel/bladder comments (add)
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MVA
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MVA details comment (add)
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Industrial injury
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Industrial injury details (add)
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Work comp insurance carrier
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Work comp claim number (add)
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Work comp claims adjuster
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Work comp claims adjuster comment (add)
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Attorney
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Attorney name (add)
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Visaual analog pain scale (VAS)
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VAS comments (add)
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Verbal pain intesity scale
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Verbal pain intensity comment (add)
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Oswestry score
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ODI comment (add)
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Neck disability index
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NDI comments (add)
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Additional details regarding patient (add)
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