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I downloaded this form from a record op a few weeks ago. I beleive it was one that accepted Chiro records. Now, I'm at a loss as to where I gotit.
Thanks in advacnce to all.
PHYSICIAN EXAMINATION FORM
PATIENTS NAME PHONE ( )
Patient Address City State Zip
Date of Birth Identification
I certify I am requesting the release of this information, from whom I am receiving supplementary medical care.
PATIENT SIGNATURE Date:
The above-named patient has presented for the following complaint. The physician signing below requests a physicians physical examination and report any evidence and findings related to the patients medical complaint recorded below. Please forward the results to the physician at the address shown below.
PATIENTS PRIMARY MEDICAL COMPLAINT:
Requesting Physician Signature:
Examining Physicians Name Phone ( )
Organization, facility, of affiliation Fax ( )
Address City State Zip
Physicians Findings.
YES NO Decreased range of motion of affected areas
YES NO Surgical scar(s)
YES NO Crepitus
YES NO Pain upon palpitation
YES NO Does patient verify chronic migraine complaint? Does cervical region examination reveal any related significant abnormalities or findings?
YES NO Other
Examining Physician signature: Date:
Patient should keep a copy of this form when completed.
I have the same form. just got it filled out and it was NWW.I was wondering what this form actually does-does this give them the ability to now contact my primary doc? She did fill it out so I'm not concerned in that respect.or is this good enuff for a temporary record?
tony
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