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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