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VASCULAR
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Dorsalis Pedis Pulse Left
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Dorsalis Pedis Pulse Right
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Posterior Tibial Pulse Left
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Posterior Tibial Pulse Right
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Capillary Refill Left Foot
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Capillary Refill Right Foot
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Ischemic Skin Changes Left LE
• • •
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Ischemic Skin Changes Right LE
• • •
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Skin Temperature Left LE
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Skin Temperature Right LE
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Muscle Tone
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Vascular Comment
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NEUROLOGICAL
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Alert and Oriented X
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Coordination
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Sensation
• • •
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SWMF Left Foot - Non Diabetic
• • •
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SWMF Right Foot - Non Diabetic
• • •
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SWMF Left Foot - Diabetic
• • •
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SWMF Right Foot - Diabetic
• • •
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Neurological Comment
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DERMATOLOGICAL
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Nails Left Foot
• • •
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Nails Right Foot
• • •
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Edema Left LE
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Edema Right LE
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Dermatologic Comment
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MUSCULOSKELETAL
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Foot Posture Left
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Foot Posture Right
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Structural Deformities
• • •
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Structural Deformities Comment
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Muscle Strength Left Foot
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Muscle Strength Right Foot
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Muscle Strength Left Leg
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Muscle Strength Right Leg
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Range of Motion
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Musculoskeletal Comment
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PLAN
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Referral
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Referrals Needed
• • •
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Referral Comment
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Plan
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Plan
• • •
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