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Reason for visit?
• • •
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New to The Treatment?
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If other, what?
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New to provider?
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Area(s) of concern
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Other notes regarding this patient or this visit?
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If other, what?
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Is patient open to sharing photos?
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Has patient had treatment before?
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Loss of smell/taste?
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N/V/D?
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Recent travel?
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Any exposure to contagious condition?
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Any known contagious condition?
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Current Fever w/in last 24 hours?
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