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SUBJECTIVE
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Headaches
• • •
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Insomnia
• • •
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Neck Pain
• • •
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Mid Back Pain
• • •
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Low back Pain
• • •
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Trapezius Spasm
• • •
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LUE
• • •
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RUE
• • •
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LLE
• • •
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RLE
• • •
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Other
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Difficulty with Concentration or Memory
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Difficulty with Activities of Daily Living
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ALLERGIES
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Current Medications
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Review of Symtoms
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General [-]
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General
• • •
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General
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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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Neurological
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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 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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MSK WNL
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MSK Abnormal
• • •
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MSK Comments
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Point of tenderness
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Breasts WNL
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Breasts Abnormal
• • •
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Breasts 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 Comments
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Body diagram
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Assessment
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ASSESSMENT
• • •
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Assessment
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Plan
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Plan
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PLAN
• • •
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Recommendations
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Procedures
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Anti-inflammatory to control soft tissue inflammation and pain, Using
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Headache medications to control injury related headaches, Using
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Antispasmodic to decrease muscle hypertonicity and improve sleep, Using
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Narcotic pain medications for short term relief of extreme pain, Using
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X-Rays orders
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Any other testing
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Physician’s Initials
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