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Chief Complaint
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Chief complaint
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History of the Present Illness
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RECENT PAIN RELIEF
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Narrative
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Quality
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VAS Score
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History of the pain
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Treatment
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Medical History
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Past Surgical Hist Comments
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Childhood illnesses
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Childhood Illness Comments
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Date of last PE
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Social History
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Occupation
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Currently Working
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Occupation Cont
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Date of Injury
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Caffeine
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Caffeine Comments
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Alcohol
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Alcohol Comments
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Other illegal substances
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Medications
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Allergies
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Review of Systems
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GENERAL [-]
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General ROS+
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General ROS Comments
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HEENT [-]
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HEENT ROS+
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HEENT ROS Comments
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Cardiovascular [-]
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Cardiovascular ROS+
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CV ROS Comments
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Respiratory [-]
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Respiratory ROS+
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Resp ROS Comments
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Gastrointestinal [-]
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GI ROS+
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GI ROS Comments
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Genitourinary [-]
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Genitourinary ROS+
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Genitourinary ROS Comments
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Neurological [-]
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Neurological ROS+
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Neuro ROS Comments
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Musculoskeletal [-]
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MSK ROS+
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MSK ROS Comments
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Hematological [-]
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Hematologic ROS+
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Hematologic ROS Comments
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Skin [-]
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Skin ROS+
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Skin ROS Comments
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Endocrine [-]
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Endocrine ROS+
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Endo ROS Comments
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Physical Exam
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General WNL
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General Abnormal
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General Comments
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HEENT WNL
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HEENT Abnormal
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Neck WNL
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Neck Abnormal
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Neck Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
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Abdomen Comments
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Lymph WNL
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Lymph Abnormal
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Lymph Comments
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Rectal WNL
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Rectal Abnormal
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Rectal Comments
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Neuro WNL
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Neuro Abnormal
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Neuro Comments
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Extremities WNL
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Extrem Abnormal
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Extrem Comments
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Alignment/Gait
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Abnormal Comments
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Physical - Back Pain
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Back Pain - Appearance
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Abnormality Comments
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Palpation
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AROM- fwd flex (75 deg)
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AROM- hyper ext (20 deg)
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AROM- lat flex (20-30 deg)
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AROM- rotation (40 deg)
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Specific Tests
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Straight leg raising (Deg)
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Lhermitte’s sign
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SI joint
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Wadell’s
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Piriformis stretch
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Leg length discrepancy
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Motor testing of all muscle groups
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Deep tendon reflexes
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Sensory loss
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Laboratory Results
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Imaging & other studies
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Assessment & Plan
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