Initial evaluation

Published July 12, 2015

Here is a sample initial evaluation. I take my time with every patient and jot down findings that are present or absent in particular tests. Each finding may or may not mean something and help lead to a diagnosis. With this information, it is part of your file and once it is part of the file, it is part of the file. What I mean by that is you can always go back to what you said at the beginning and discuss it on the stand.

Patient:  Nick

Date of service:

Date of birth:

Date of injury:

Nick reports to . . .

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