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TELE-HEALTH VISIT
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Title (Last Name will populate)
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Notes
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Telephone or video visit
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Notes
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Time and date (Free type)
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Notes
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Last evaluated on ... (Free type for now)
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Notes
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Relief from prev treatment (good or none)
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Notes
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Previous treatments
• • •
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Notes
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On a scale from 1-10, 10 being the worst, the patient rates their pain in the following manner.
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Head
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Headaches are a___/10
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Improvement
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Notes
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Neck
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Neck pain is a___/10
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Notes
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Improvement
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Notes
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Radiating - Neck L/R
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Notes
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Radiates from neck to ___
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Notes
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Paresthesia - Neck L/R
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Notes
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Upper back
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Upper back pain is a___/10
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Improvement
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Notes
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Mid back
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Mid back is a___/10
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Improvement
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Notes
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Lower back
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Lower back is a___/10
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Improvement
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Notes
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Radiating - L/R
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Notes
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Radiates from lower back to ___
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Notes
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Paresthesia - Leg L/R
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Notes
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Left shoulder
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The left shoulder pain is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Right shoulder
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The right shoulder pain is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Left Elbow
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Left elbow is a___/10
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Notes
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Right Elbow
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Right elbow is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Left Wrist
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Left wrist is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Right Wrist
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Right wrist is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Right Hand
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Right hand is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Left Hand
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Left hand is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Left Hip
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Left hip is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Right Hip
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Right hip is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Left Knee
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Left knee pain is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Right Knee
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Right knee pain is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Right Ankle
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Right ankle is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Left Ankle
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Left ankle is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Right Foot
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Right foot is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Left Foot
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Left foot is a___/10
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Improvement
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Notes
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Limited ROM (Yes or No)
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Notes
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Notes
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The patient states that the pain continues to prevent them from their routine daily activities.
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They state that the pain is worse _____
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Notes
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The pain is exacerbated by_____
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Notes
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They have tried treating the pain with_____
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Notes
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The patient has deficits performing_____
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Notes
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% of improvement for Epidural
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Notes
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Area
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Notes
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Past Procedure
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Notes
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Return of symptoms
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Notes
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Recommend Procedure
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Procedure
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Notes
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WC
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Notes
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DOA:
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Employer at time of accident:
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Occupation at the time of the accident:
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Job Duties:
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Currently Working: Yes (FT/ PT) or No
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Date last worked? (type full date with year)
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% of disability
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WC Notes (Add any restrictions or upcoming surgeries/hearings) related to case
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Past Medical History
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Notes
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Past Surgical History
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Notes
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Medications
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Notes
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Allergies
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Notes
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Family
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Non-Contributory
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No significant family history.
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The patient was adopted.
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Mother_____
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Please select from the following
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Father_____
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Please select from the following
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Social
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Alcohol use
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Notes
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Smoking
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Notes
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The patient smokes
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cigarettes/packs
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a day/a week
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Occupation
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Work Status:
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If Working Occupation and Employer (Please type)
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The patient has not been working since the accident.
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Notes
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Review of Systems
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The patient denies fevers, chills, shortness of breath, chest pains, visual changes and bowel/bladder incontinence.
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The patient states they have trouble sleeping at night because of the pain.
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Notes
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IMAGING STUDIES
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Notes
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IMPRESSION/DIAGNOSIS
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HEAD DIAGNOSIS
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Others, please specify
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CERVICAL DIAGNOSIS
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Others, please specify
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THORACIC - Upper Back
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Others, please specify
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THORACIC - Mid Back
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Others, please specify
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LUMBAR
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Others, please specify
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LEFT SHOULDER
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Others, please specify
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RIGHT SHOULDER
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Others, please specify
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LEFT ELBOW
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Others, please specify
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RIGHT ELBOW
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Others, please specify
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LEFT WRIST
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Others, please specify
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RIGHT WRIST
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Others, please specify
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LEFT HIP
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Others, please specify
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RIGHT HIP
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Others, please specify
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LEFT KNEE
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Others, please specify
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RIGHT KNEE
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Others, please specify
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RIGHT ANKLE
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Others, please specify
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LEFT ANKLE
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Others, please specify
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RIGHT FOOT
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Others, please specify
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LEFT FOOT
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Others, please specify
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SACRUM
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Others, please specify
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PLAN
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Continue with present medications.
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Continue with Chiropractic treatment as per treating Doctor
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PT
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Notes
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times/week
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Notes
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week time
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Notes
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massage
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Notes
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times/week
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Notes
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week time
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Notes
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accu
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Notes
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times/week
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Notes
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week time
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Notes
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MRI
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Notes
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symptoms
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Notes
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Xray
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Notes
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was ordered and will follow up results.
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Notes
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EMG
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studies ordered and will follow up results.
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studies were recommended.
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Notes
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I have reviewed all imaging studies and reviewed results with the patient.
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Notes
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I have reviewed the medical records of the
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Notes
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practitioner
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Notes
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I have discussed several treatment options and the risks and benefits of conservative pain management treatment and continued ph
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Notes
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I have stressed the importance of a home exercise program including stretching to maintain range of motion and improve overall f
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Notes
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I will schedule for
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treatment
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next visit if symptoms persist and do not improve with therapy.
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Notes
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I will schedule for a
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epidural
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in an effort to significantly improve their normal functioning capacity.
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Notes
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The patient has responded well to lumbar median nerve branch blocks, though the pain has since returned. It is indicated at this
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Notes
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The patient was given an appointment to follow up in
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Notes
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number
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Notes
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day/week
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Notes
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PRN for pain management.
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Notes
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Notes
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Antoniou
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Antoniou
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Agulnick
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Deep
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Deep
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Katsigiorgis
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Audiino
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Audiino
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Beltrani
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Beltrani
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Bracco Anthony
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Bracco Anthony
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Bracco
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Bracco
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Brown
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Brown
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Bugay Maria
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Bugay Maria
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Bugay
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Bugay
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Castro Lee
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Castro Lee
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DeRosa
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DeRosa
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Dillon
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Donnelly
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Donofrio
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Donofrio
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Egner
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Egner
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Fink
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Fink
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Gliganic
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Gliganic
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Gonzalez
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Gonzalez
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Graff
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Graham
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Graham
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Greene
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Hilderbrand
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Hilderbrand
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Krosney
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Lora
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Lora
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Magee
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Martinez
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Martinez
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Mensah
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Michiel
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Navarra
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Navarra
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Nova
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Nova
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Pace
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Nancy Paul
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Paul Nancy
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Petchonka
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Petchonka
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Poole
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Poole
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Porti
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Porti
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Rizza Rosas
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Rizza Rosas
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Saint Jean
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Saint Jean
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Sawyer Emily
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Sawyer Emily
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C Smyth
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Smyth
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Smyth
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Stamatelatos
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Stamatelatos
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Taheri
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Tengco
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Venditti
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Ververis
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Ververis
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Waxman
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Waxman
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Wozowcyzk
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Wozowczyk
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Zuluaga
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Zuluaga
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