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Primary Complaint:
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When did the pain start?
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Pain Diagram
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Quality of CC
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Mechanism of Injury
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Duration of CC
• • •
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Severity of CC
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Scars:
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What makes CC worse
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What makes CC feel better
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Comments on CC
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Previous Treatment
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Progress since last treatment:
• • •
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Progress Comments
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Additional Info
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Additional Complaint(s)
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When did the pain start?
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Pain Diagram for AC
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Quality of AC
• • •
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Mechanism of Injury
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Duration of AC
• • •
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What makes AC worse
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What makes AC feel better?
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Severity of AC
• • •
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Previous Treatment
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Comments on AC
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Additional Info
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Progress since last treatment:
• • •
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Progress Comments
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Homework Compliance
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