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Clinical Problems
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Onset
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Aggravating/Associated Symptoms
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Nausea
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Vomiting
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Constipation
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Itching
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Sweating
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Fatigue
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Drowsiness
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Difficulty Concentrating
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Medications & Dosages
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Status: (Compliance)
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Depression Score: PHQ2: PHQ9:
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Analgesia
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Average pain level in the past month? (scale of 0-10)
/
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Pain relief with current meds: (%)
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Daily Living (ADL)
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Physical functioning
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Family Relationship
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Social Relationship
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Mood
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Sleep
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Work Performance
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Overall Functioning
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Adjunct Therapy
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Cold
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Heat
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Relaxation
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Physical Therapy
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Chiropractic
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Massage
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Diagnostic: (Performed and Completed)
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X-ray
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X-ray Comment
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CT
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CT Comment
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MRI
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MRI Comment
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Special Management
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Pain Management
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Neurology
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Rheumatology
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Surgery
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Behavioral Health
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Aberrant Behavior
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Appears Unkept
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Appears Intoxicated
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Request Early Refill
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Reports lost/stolen Rx
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Reports alcoholism or drug abuse
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Recent Arrest
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Compliance
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New Subheader
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Controlled Substance Agreement
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Last Date
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Frequency
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Due Date
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PMP
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Last Date
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Frequency
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Due Date
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Pill Count
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Last Date
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Frequency
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Due Date
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Urine Tox Screen
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Last Date
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Frequency
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Due Date
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Urine Tox Interpretation
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Urine Tox Interpretation
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Urine Tox Interpretation
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