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Follow up visit
|
|
|
Follow up
• • •
|
|
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HOPI
|
|
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Meds refill
|
|
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current meds
• • •
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effectiveness
• • •
|
|
compliant with meds intake
|
analgesia
|
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aberrant behavior
|
PDMP reviewed
|
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UDx review
|
|
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New Patient
|
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New Patient HPI
|
|
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Personal Injury
|
|
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Date of Injury
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Attorney Representation
|
|
LOP HOPI
|
|
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Seat belts
|
Loss of conciousness
|
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Pain onset
• • •
|
Pain onset Comments
|
|
Location
• • •
|
Location Comments
|
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Duration
• • •
|
Duration Comments
|
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Quality
• • •
|
Quality Comments
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Severity
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Severity Comments
|
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Aggravating factors
• • •
|
Aggravating Factors Comments
|
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Relieving factors
• • •
|
Relieving Factors Comments
|
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Associated Symptoms
• • •
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Associated Symptoms Comments
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Additional Issues [+]
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|
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Numbness/Tingling?
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Sitting
|
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Radiating Pain?
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Standing
|
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Walking
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Twisting
|
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Laying Down
|
Bending Forward
|
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Bowel/Bladder Dysfunction?
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Awakened by Pain?
|
|
Patient Concerns
• • •
|
Concerns Comments
|
