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New Patient?
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Follow-Up?
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PCP
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PCP Tel / Fax
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Referring MD
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Referring MD Tel / Fax
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DOB / AGE / SEX
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Handedness
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Ethnicity
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Chief Complaint (s)
• • •
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Chief Complaint (other)
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Medical Conditions
• • •
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Medical Conditions (Other)
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History
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PROBLEM #1
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Onset
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Description
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Tests / Evals done so far
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Tx / Rx done so far
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PROBLEM #2
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Onset
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Description
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Tests / Evals done so far
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Tx / Rx done so far
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PROBLEM #3
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Onset
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Description
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Tests / Evals done so far
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Tx / Rx done so far
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PROBLEM #4
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Onset
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Description
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Tests / Evals done so far
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Tx / Rx done so far
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PROBLEM #5
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Onset
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Description
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Tests / Evals done so far
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Tx / Rx done so far
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Neurological Review of Systems
• • •
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Epworth Scale
• • •
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Epworth Score
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ROS: Constitutional
• • •
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ROS: HEENT
• • •
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ROS: Endocrinologic
• • •
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ROS: Gastrointestinal
• • •
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ROS: Genitourinary
• • •
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ROS: Respiratory
• • •
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ROS: Integumentary
• • •
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ROS: Cardiovascular
• • •
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ROS: Musculoskeletal
• • •
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ROS: Hematologic/Immunologic
• • •
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ROS: Psychiatric
• • •
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ROS: Neurologic
• • •
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Allergies
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Medications
• • •
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List of allergies
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Recent Labs or Tests
• • •
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Records reviewed
• • •
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Social history
• • •
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Family Hx: Father
• • •
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Family Hx: Mother
• • •
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Family Hx: Siblings
• • •
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Family Hx: Children
• • •
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Family Hx: Relatives
• • •
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Neuro Exam normal
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Brief Normal Neuro Exam
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Abnormal Findings In
• • •
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Describe abnormal findings
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Mental Status normal
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Normal Psych Assessment
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Mini-Mental Status Exam
• • •
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MMSE score
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Mental Status comments
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Cranial Nerves normal
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Cranial Nerves comments
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CN I
• • •
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CN II
• • •
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CN III, IV, VI
• • •
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CN V
• • •
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CN VII
• • •
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CN VIII
• • •
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CN IX, X
• • •
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CN XI
• • •
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CN XII
• • •
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Neck / Spine normal
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Neck / Spine comments
• • •
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Back / Spine normal
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Back / Spine Comments
• • •
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Motor Exam normal
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Motor Exam comments
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Motor Exam comments
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Muscle 1
• • •
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Muscle 1 Grade
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Muscle 2
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Muscle 2 Grade
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Muscle 3
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Muscle 3 Grade
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Muscle 4
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Muscle 4 Grade
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Muscle 5
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Muscle 5 Grade
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Muscle 6
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Muscle 6 Grade
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Muscle 7
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Muscle 7 Grade
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Muscle 8
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Muscle 8 Grade
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Muscle 9
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Muscle 9 Grade
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Muscle 10
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Muscle 10 Grade
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Muscle 11
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Muscle 11 Grade
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Muscle 12
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Muscle 12 Grade
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Muscle 13
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Muscle 13 Grade
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Muscle 14
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Muscle 14 Grade
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Muscle 15
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Muscle 15 Grade
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Muscle 16
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Muscle 16 Grade
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Muscle 17
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Muscle 17 Grade
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Muscle 18
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Muscle 18 Grade
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Muscle 19
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Muscle 19 Grade
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Muscle 20
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Muscle 20 Grade
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Coordination normal
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Coordination comments
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Coordination Exam RT side
• • •
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Coordination Exam LT side
• • •
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Reflexes normal
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Reflexes
• • •
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Plantar responses
• • •
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Sensory Exam normal
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Sensory Exam comments
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Sensory Exam RUE
• • •
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Sensory Exam RUE
• • •
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Sensory Exam RLE
• • •
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Sensory Exam RLE
• • •
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Sensory Exam LUE
• • •
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Sensory Exam LUE
• • •
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Sensory Exam LLE
• • •
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Sensory Exam LLE
• • •
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Gait normal
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Gait comments
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Gait Exam
• • •
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EDSS score
• • •
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Auscultation normal
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Auscultation comments
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Neurological Signs
• • •
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Other pertinent exam findings
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Neurological Localization
• • •
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DIFFERENTIAL (categories)
• • •
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DIFFERENTIAL (causes)
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SUMMARY
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IMPRESSION #1 (Neuro)
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Differential?
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Neuro DDx
|
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Neuro DDx (list)
• • •
|
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IMPRESSION #2 (Neuro)
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Differential?
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Neuro DDx
|
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Neuro DDx (list)
• • •
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IMPRESSION #3 (Neuro)
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Differential?
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Neuro DDx
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Neuro DDx (list)
• • •
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IMPRESSION #4 (Neuro)
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Differential?
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Neuro DDx
|
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Neuro DDx (list)
• • •
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IMPRESSION #5 (Neuro)
|
Differential?
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Neuro DDx
|
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Neuro DDx (list)
• • •
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COMMENTS
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ASSESSMENT (Other)
|
|
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PLAN: Labs
• • •
|
|
|
PLAN: CSF Studies
• • •
|
|
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PLAN: Other Studies
|
|
|
PLAN: Radiology
• • •
|
|
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PLAN: Neurodiagnostics
• • •
|
|
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PLAN: Physical Therapy
• • •
|
|
|
PLAN: Home Health
• • •
|
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PLAN: Referrals
• • •
|
|
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PLAN: Education
• • •
|
|
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PLAN: Diet
• • •
|
|
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PLAN: General Instructions
• • •
|
|
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PLAN: Meds / Dose
|
|
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PLAN: Meds / Dose
|
|
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PLAN: Meds / Dose
|
|
|
PLAN: Meds / Dose
|
|
|
PLAN: Meds / Dose
|
|
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PLAN: Meds / Dose
|
|
|
PLAN: Meds / Dose
|
|
|
PLAN: Medications Refilled
|
|
|
PLAN: Medication Instructions
• • •
|
|
|
PLAN: Other Specific Orders
|
|
|
FOLLOW-UP
• • •
|
|
|
Total time spent
• • •
|
|
|
|
|
|
SALUTATION
|
|
