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SUBJECTIVE
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Chief Complaint:
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General Statements:
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History of Present Illness:
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General Statements:
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Medical History:
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Surgical History:
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Current Medications:
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Allergies:
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Review of Systems
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Constitutional: [-]
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Constitutional:
• • •
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General Comments:
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HEENT: [-]
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HEENT:
• • •
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General Comments:
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Respiratory: [-]
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Respiratory:
• • •
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General Comments:
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Cardiovascular: [-]
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Cardiovascular:
• • •
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General Comments:
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Gastrointestinal: [-]
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Gastrointestinal:
• • •
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General Comments:
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Neurological: [-]
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Neurological:
• • •
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General Comments:
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Genitourinary: [-]
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Genitourinary:
• • •
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General Comments:
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Musculoskeletal: [-]
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Musculoskeletal:
• • •
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General Comments:
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Skin: [-]
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Skin:
• • •
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General Comments:
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Psychiatric: [-]
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Psychiatric:
• • •
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General Comments:
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Endocrine: [-]
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Endocrine:
• • •
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General Comments:
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Hematologic/Lymphatic: [-]
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Hematologic/Lymphatic:
• • •
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General Comments:
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Allergic/Immunologic: [-]
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Allergic/Immunologic:
• • •
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General Comments:
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OBJECTIVE
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Pre Treatment Vital Signs
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Height:
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Weight:
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Temperature
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Heart Rate:
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Blood Pressure
/
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Respiratory Rate:
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02 Saturation:
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General Statements:
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Physical Exam
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General WNL:
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General Abnormal:
• • •
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General Comments:
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Cardiovascular WNL:
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Cardiovascular Abnormal:
• • •
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General Comments:
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Respiratory WNL:
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Respiratory Abnormal:
• • •
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General Comments:
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Gastrointestinal WNL:
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Gastrointestinal Abnormal:
• • •
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General Comments:
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Musculoskeletal WNL:
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Musculoskeletal Abnormal:
• • •
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General Comments:
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Neurological WNL:
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Neurological Abnormal:
• • •
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General Comments:
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Skin WNL:
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Skin Abnormal:
• • •
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General Comments:
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Post Treatment Vital Signs
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Weight:
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Height:
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Temperature
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Heart Rate:
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Blood Pressure
/
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Respiratory Rate:
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02 Saturation:
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General Statements:
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ASSESSMENT
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PLAN
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Procedure Note:
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Providers Name:
• • •
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