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NEW PATIENT
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NEW COMPLAINT
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FOLLOWUP
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ANY POST OP VISIT
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Chief Complaint (Ortho)
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Chief Complaint (HRT)
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Chief Complaint(s) (Ortho)
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Chief Complaint (HRT)
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History of Chief Complaint
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Date of Injury
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History of present illness
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Description of symptoms
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Severity
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Duration
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What have you tried?
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what aggravates pain/symptoms
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What relieves the pain?
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Any mechanical symptoms?
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Better Same or Worse?
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Seen any other doctor for this problem?
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If yes, who and when?
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HRT
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Weight Gained
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Weight Gained
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Increased blood sugar
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Increased blood Pressure
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Decrease in Muscle size, tone, strength?
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Decrease in muscle size, tone or strength [+]
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Decreased physical capabilities/performance
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Decreased physical capabilities
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Fatigue
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When and how often
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Decreased mental sharpness
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[+] decreased mental sharpness
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Morning erections
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Morning erections
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Decreased Libido
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Libido
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Erectile Dysfunction
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erectile dysfunction
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MVA
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Workers Comp
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Motor vehicle accident?
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Worker's Comp. Related
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Date Of Accident
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Vehicle Info:
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Type of vehicle
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Other
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Location of impact
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Airbags Deploy?
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Patient/Passenger Information
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Driver?
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Seatbelt
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Were others injured
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symptoms directly related to mva
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seen another provider since ER
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treatment
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Go to hospital
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transportation to hospital
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represented by an attorney
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Attorney's name
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Date of accident
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Place of employment
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Daily activity/ Work activity
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What is your job description?
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Have you been seen for the injury
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If yes, by whom?
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Was the injury reported same day?
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If no, Why?
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Testing done
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Treatment
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is an attorney involved?
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If yes, who?
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Symptoms related to injury
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Work status since injury
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Any previous X-rays or MRl's?
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If yes, When and how?
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What is your job description?
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Daily activity/ Work activity
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PT
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PT
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PT location
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PT. Location:
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Times per Week
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Continue w/ PT
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Restrictions:
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Restrictions
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Post-OP
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Type of Surgery
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Date of sx
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Pain Scale
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Improvement since surgery
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Pleased with surgery rating
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Comments
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Preferred pharmacy
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Preferred Pharmacy contact information
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PCP
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PCP Contact Information
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