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Name: Section: Date:

Disease: Submitted to:

I. PATHOPHYSIOLOGY (ETIOLOGY)

A. Flow Chart
B. Summarized Narrative

II. SIGNS AND SYMPTOMS


Subjective: Objective:
III. LABORATORY AND DIAGNOSTICS

IV. MEDICAL TREATMENT / MEDICATIONS


V. FDAR
Date/Time Focus D-data A-action R-response
V. FDAR
Date/Time Focus D-data A-action R-response

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