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History
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History
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mental status
• • •
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comments
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emotional state
• • •
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comments
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Weight change
• • •
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comments
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Libido Change
• • •
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comments
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Erectile Dysfunction
• • •
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comments
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fatigue
• • •
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comments
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daytime Sleepiness
• • •
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comments
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Changes in sleep habits
• • •
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comments
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change in physical capabilities/performance
• • •
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comments
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Seen another doctor for any reason
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If Yes, explain
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medication change
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Name of meds changed
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Neck/Low back pain
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If Yes, explain
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Joint pain and swelling
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If Yes, explain
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muscle soreness or stiffness
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If Yes, explain
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Injection Note
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Injected by
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Medication
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mg injected
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Location
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Lot Number
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Exp. Date
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Take home
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Total mL given to patient
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Amount injected weekly
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Next Appt
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note
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Assessment:
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