RM: _________________________

RM: _________________________

RM: _________________________

RM: _________________________

RM: _________________________

PT: __________________________

PT: __________________________

PT: __________________________

PT: __________________________

PT: __________________________

DX: _________________________

DX: _________________________

DX: _________________________

DX: _________________________

DX: _________________________

____________________________

____________________________

____________________________

____________________________

____________________________

ALLERGIES: _________________

ALLERGIES: _________________

ALLERGIES: _________________

ALLERGIES: _________________

ALLERGIES: _________________

____________________________

____________________________

____________________________

____________________________

____________________________

IVs: ________________________

IVs: ________________________

IVs: ________________________

IVs: ________________________

IVs: ________________________

____________________________

____________________________

____________________________

____________________________

____________________________

DIET: _________ O2@ _________

DIET: _________ O2@ _________

DIET: _________ O2@ _________

DIET: _________ O2@ _________

DIET: _________ O2@ _________

TELE: _______________________

TELE: _______________________

TELE: _______________________

TELE: _______________________

TELE: _______________________

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