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Chief Complaint
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New Patient
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New Condition
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Follow-Up
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Pre-Op
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MRI Review
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MRI Review Fields
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Side
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Imaging Type
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Imaging Location
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Imaging Location (free-text)
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Date of Service
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Conditions Being Evaluated
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Availability of Images/Report
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Pre-Op Fields
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Side
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Surgical Procedure
• • •
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Date of Surgery
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Surgery Location
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HPI
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HPI
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Since the last visit (time)
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the patient feels
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Duration of symptoms
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Acute Onset?
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Were symptoms from fall/trauma
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Were symptoms from gradual onset?
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Location of pain
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Pain Score
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Does the pain radiate?
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Effusion at any time?
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Swelling at any time?
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Locking or catching?
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Instability?
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Immobilization?
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Night symptoms?
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Numbness or tingling?
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Has the patient done physical therapy?
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Progress with physical therapy?
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Previous MRI
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Denies previous history/treatment
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How many cortisone/HA/PRP injections?
• • •
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Denies Medication
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Medications
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Work Status
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Additional Information
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