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Chief Complaint/Presenting Illness
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Proposes Procedure
|
|
No Allergies or Sensitivities
|
Known Allergies or Sensitivities
|
|
Medical Surgical History
|
|
|
|
|
|
General - no change
|
Comments
|
|
HEENT - no change
|
Comments
|
|
Skin - no change
|
Comments
|
|
Lungs - no change
|
Comments
|
|
Cardiovascular - no change
|
Comments
|
|
GI/Abdomen - no change
|
Comments
|
|
GU - no change
|
Comments
|
|
Neuro - no change
|
Comments
|
|
MSK - no change
|
Comments
|
|
Mental Status- no change
|
Comments
|
|
Extremities - no change
|
Comments
|
|
Neck - no change
|
Comments
|
|
Impression - PT Ready for Surgery
|
Impression - PT NOT READY for Proc
|
|
Signature
|
|
