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Patient Intake & History
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Patient Intake & History
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Subjective
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Chief Complaint
• • •
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Other
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Pain Scale (0-10)
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Other
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History of Present Illness (HPI)
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Onset
• • •
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Other
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Location
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Other
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Duration
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Other
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Functional Impairment
• • •
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Other
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Pain Frequency
• • •
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Other
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Pain Description
• • •
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Other
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Aggravating Factors
• • •
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Other
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Alleviating Factors
• • •
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Other
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Previous Interventions
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Medications
• • •
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Other
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Physical Therapy
• • •
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Other
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Injections
• • •
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Other
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Imaging
• • •
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Other
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Objective
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Physical Exam Inspection
• • •
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Other
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Palpation
• • •
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Other
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Range of motion
• • •
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Other
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Strength Testing
• • •
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Other
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Deep Tendon Reflexes
• • •
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Other
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Imaging
• • •
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Other
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Sensation
• • •
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Other
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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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Lower Extremity Image 4
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Assessment
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Medical Necessity Justification
• • •
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Other
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Treatment Plan
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Impression
• • •
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Other
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Treatment Plan
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Referrals
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Follow-Up
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Other
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Patient Education
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Patient Education
• • •
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Billing
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Diagnosis Codes (ICD-10)
• • •
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Billing Services
• • •
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