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Subjective
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Symptom
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Other please specify
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Objective
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Area(s) of Examination Findings
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Areas Treated
• • •
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Other please specify
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Body Diagram
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Specifics
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Pain Scale (circle if applicable; arranged lowest to highest)
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Interventions
• • •
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Assessment / Plan
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Result(s)
• • •
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Additional Notes (if any)
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