Mr./Mrs. ======= is a == -year-old who is seen today for evaluation of the ===. Pt Primary Language Spoken: ==. Pt lives in == story home with family.
Personal Factors and Co-morbidities: PMH: ==; (refer to Medical Section for additional medical conditions.)
Patient reports ==
Patient sought medical attention from primary care physician, Dr. ====, and had X-rays/MRI that revealed==
Patient has now been referred to therapy for evaluation and treatment of current condition.
CHIEF COMPLAINT:
AGGRAVATING FACTORS:
EASING FACTORS:
SENSATION: Intact, patient reports no numbness, tingling nor burning
OCCUPATION:
IMAGING:
PRIOR LEVEL OF FUNCTION: Ability to
FACTORS IMPACTING PLAN: Currently,
Patient describes goals for therapy as restoring =====.
Medicaid Patient must Include: Patient's mother === was present and provided consent for treatment. It was established that ==== is the primary responsible adult and is expected to be involved with patient's treatment.