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Texas Wellness Center
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Chart ID:
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Date:
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Patient Name:
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Date of Incident:
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Date of Birth:
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Gender:
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Medical Report
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Chief Complaint/ History of Present Illness:
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1) HEENT:
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Incident Details:
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2) Respiratory System:
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Past Medical/Surgical History:
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3) Gastrointestinal System
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Allergies:
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4) Renal System
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Current Medications:
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5) Reproductive System
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Initial Medical Evaluation:
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6) Musculoskeletal System
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Physical Examination:
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6.1 - Spine
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Cervical Region:
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Lumbar Region:
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Thoracic Region:
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Sacroiliac Region:
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6.2 - Upper Extremity
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Shoulder:
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Arm:
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Elbow:
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Forearm:
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Wrist:
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Hand:
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6.3 - Chest
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Sternum:
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Rib Cage:
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Scapula:
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6.4 - Abdomen
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List Findings:
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6.5 - Lower Extremity
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Pelvis:
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Ankle
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Knee:
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Foot:
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Diagnostic Test
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Diagnosis
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Plan
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1) Physical Therapy:
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Signature:
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Date:
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