Admit: DOA:

ID: ID:
CC: CC:

PE Notes: PE Notes:

ROOM: ROOM:
PMHx/PSurgHx: Home Meds: PMHx/PSurgHx: Home Meds:

ALL: ALL:
ROS: ROS:
SHx: PMD/Consults: SHx: PMD/Consults:

FamHx: FamHx:

PROBLEM LIST PROBLEM LIST

Ca Ca
1 Mg 1 Mg
Ph Ph
2 2
3 3
4 P L M E B 4 P L M E B

5 5
6 6
7 7
8 8
9 9
NOTES MEDS NOTES MEDS
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