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Triage Assessment
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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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Date of last PE
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PCP
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PCP Contact Information
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Family History
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Paternal MH
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Comments
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Maternal MH
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Comments
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Sibling(s)' MH
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Comments
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Social History
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Marital Status
• • •
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Occupation
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Alcohol
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Tobacco
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Packs per day
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Does the patient feel safe
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Triage Signature
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Menstrual cycle
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Last Menstrual Period
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Gravity
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PARA
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Elective Abortion
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Spontaneous Abortion
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Review of Symptoms
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General [-]
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General
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General Comments
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Skin [-]
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Skin
• • •
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Skin
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HEENT [-]
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HEENT
• • •
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HEENT
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Neck [-]
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Neck
• • •
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Neck
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Breasts [-]
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Breasts
• • •
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Breasts
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Cardiovascular [-]
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Cardiovascular
• • •
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Cardiovascular
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Respiratory [-]
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Respiratory
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Respiratory
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GI [-]
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GI
• • •
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GI
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Urinary [-]
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Urinary
• • •
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Urinary
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MSK [-]
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MSK
• • •
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MSK
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Neurological [-]
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Neurological
• • •
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Neuro
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Endocrine [-]
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Endocrine
• • •
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Endo
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Psychiatric [-]
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Psychiatric
• • •
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Psychiatric
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Physical Exams
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General WNL
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General Abnormal
• • •
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General
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HEENT WNL
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HEENT Abnormal
• • •
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HEENT
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Skin WNL
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Skin Lesion
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Skin
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Neck WNL
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Neck Abnormal
• • •
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Neck
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Cardiovascular WNL
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Cardiovascular Abnormal
• • •
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Cardiovascular
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Lungs WNL
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Lungs Abnormal
• • •
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Lungs
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Abdomen WNL
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Abdomen Abnormal
• • •
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Abdomen
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MSK WNL
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MSK Abnormal
• • •
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MSK
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Breasts WNL
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Breasts Abnormal
• • •
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Breasts
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Neuro WNL
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Neuro Abnormal
• • •
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Neuro
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Extremities WNL
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Extrem Abnormal
• • •
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Extrem
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Assessment
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Assessment
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Plan
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In-House Labs
• • •
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Lab work (outside labs)
• • •
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X-RAYS
• • •
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Radiology Comments
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Medications INJ/PO
• • •
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Medication dosage
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IV Therapy
• • •
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Orthopedic
• • •
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Cardiology
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Respiratory Therapy
• • •
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Respiratory Therapy
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Other
• • •
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Results
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Referrals
• • •
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Referral
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General Instructions
• • •
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General Instruction Comments
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