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Telemedicine Consent
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History of Present Illness
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Review of Systems
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General- Patient Denies
• • •
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General- Patient Confirms
• • •
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General Text Field
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Eyes- Patient Denies
• • •
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Eyes- Patient Confirms
• • •
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Eyes Text Field
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Ears/Nose/Mouth/Throat- Patient Denies
• • •
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Ears/Nose/Mouth/Throat- Patient Confirms
• • •
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Ears/Nose/Mouth/Throat Text Field
|
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Cardiovascular- Patient Denies
• • •
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Cardiovascular- Patient Confirms
• • •
|
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Cardiovascular Text Field
|
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Respiratory- Patient Denies
• • •
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Respiratory- Patient Confirms
• • •
|
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Respiratory Text Field
|
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Genitourinary- Patient Denies
• • •
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Genitourinary- Patient Confirms
• • •
|
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Genitourinary Text Field
|
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Musculoskeletal
• • •
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Musculoskeletal Text Field
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Skin- Patient Denies
• • •
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Skin- Patient Confirms
• • •
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Skin Text Field
|
|
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Heme/Lymph- Patient Denies
• • •
|
Heme/Lymph- Patient Confirms
• • •
|
|
Heme/Lymph Text Field
|
|
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Neurological- Patient Denies
• • •
|
Neurological- Patient Confirms
• • •
|
|
Neurological Text Field
|
|
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Psychiatric- Patient Denies
• • •
|
Psychiatric- Patient Confirms
• • •
|
|
Psychiatric Text Field
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Exercise Text Field
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Sleep Text Field
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Past Medical History
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Past Medical History
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Family History
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Family History
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Social History
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Social History
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Allergies
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Allergies
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Medications
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Medications
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Physical Examination
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Physical Examination
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General
• • •
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Text Field
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Eyes
• • •
|
Text Field
|
|
Pulmonary
• • •
|
Text Field
|
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Skin
• • •
|
Text Field
|
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Musculoskeletal
• • •
|
Text Field
|
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Neuro/Psych
• • •
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Text Field
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Laboratory Data
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Laboratory Data
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Impression
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Assessment & Plan
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Assessment
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Plan
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Smoking Cessation Counseling
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Time Spent Statement
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