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Patient Name:
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Chief Complaint:
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Referring Physician:
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Primary Care Physician:
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Pre-procedure Diagnoses:
• • •
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Post-procedure Diagnoses:
• • •
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Proc. Performed/# areas or musc:
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Proc. Performed/# series
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Proc. Performed/Ultrasound
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Procedure Note/ Position
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Proc. note/Needle type
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Proc. note/Local conc.
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Proc. note/Local vol(# in mL/Units):
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Proc. note/0.5mL Kenalog
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Proc. note/1mL Kenalog
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Proc. note/1.5mL Kenalog
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Proc. note/2mL Kenalog
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proc note/1 ml Depomedrol
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proc note/ 2ml depomedrol
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Proc. note/ Total # of Injxn
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Proc. note/ Muscles Injected
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Proc. note/Ultrasound use
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Findings/ Pre-proc. PS(#):
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Findings/ Post-proc PS(#):
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Findings/Post-proc VS:
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Plan:
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