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Exam Room
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Placed By:
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Placed by: (Free type)
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Date of Last WCC
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Vaccine up to date
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Vaccine Needed
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Chief Complaint
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Telehealth Patient Location
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Telehealth Patient Accompanied by
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Telehealth Physician Location Office
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TH Informed Consent Received
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HPI
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ROS system(s) is/are negative except HPI
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ROS Comments
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Attends Day Care
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Day Care Comment
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Past Medical History
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Past Medical History
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Family History
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Social History
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