MEDICAL ABSTRACT

NAME: __________________________________AGE:_____________SEX____________
ADDRESS:_____________________________________ DATE:_____________________
ORDER OF RECORDING:
1. Brief History: _______________________________________________________
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2. Pertinent Physical Findings: ___________________________________________
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3. Impression:
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4. Medication: ________________________________________________________
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5. Procedures:
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6. Final Diagnosis: ____________________________________________________
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7. Recommendation: ___________________________________________________
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Physician Signature over Printed Name
Lic. No. ___________
PTR No. ___________