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Patient Intake & History
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Patient Intake & History
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Patient Intake & History
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Patient Intake & History
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Subjective
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Subjective Complaint
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Other
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Patient Medical History
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Past Medical History Freewrite
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Past Surgical History
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Past Surgical History Freewrite
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Social History
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Other
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Family has a history of the following
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Other
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Medications
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Allergies
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Other
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Review of systems
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ROS other
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Patient Height
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Patient Weight
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General Wellness Assessment
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Onset
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Aggravating Factors
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Duration
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Alleviating Factors
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Conservative Treatments Attempted
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Impact on Quality of Life
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Functional Impairment
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Medical Necessity Justification
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Supporting Documentation
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Objective Findings
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Lower Extremity Image 1
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Lower Extremity Image 2
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Lower Extremity Image 3
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Image of Bottom of Both Feet
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Image of Top of both feet
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Gait Analysis
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Other
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Muskuloskeletal
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Other
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Vascular
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Other
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Dermatologic- Skin Exam
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Other
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Neurologic
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Other
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Services Performed
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Additional Imaging Reviewed
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Other
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Assessment
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Assessment/ Diagnoses
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Assessment/ Diagnoses Additional
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Plan
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Rendered Services
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Treatment Plan
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Conservative Treatment Measures
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Follow-up
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