| {9} |
{32}{10} |
|
|
{53}
|
{54}
|
|
Visit #
|
{40}
|
|
Patient
|
{1}
|
|
Date of Birth
|
{2}
|
|
Chief Complaint
|
{3}
|
|
Visit Status
|
{33}
|
|
{52}
|
{47}
|
|
Symptoms
|
{4}
|
|
Weight
|
{5} lbs
|
|
Temperature
|
{42} ℉
|
|
Allergies
|
{6}
|
|
Medications
|
{7}
|
|
Consent to Treat
|
{41}
|
|
|
|
{31}
|
{8}
|
|
{36}
|
{37}
|
|
{38}
|
{39}
|
|
{48}
|
{49}
|
|
{43}
|
{44}
|
|
|
|
|
|
|
| {61} |
|
{55}
|
{58}
|
|
{56}
|
{59}
|
|
{57}
|
{60}
|
| {50} |
{51}
|
|
{62}
|
{63}
|
|
Provider
|
| {11} |
| {12} |
| {13} |
| {14} |
| {15} |
|
|
|
Primary Care
|
| {16} |
| {17} |
| {18} |
| {19} |
| {20} |
|
|
|
Insurance
|
| {21} |
| Insured: |
{22} |
| Subscriber DOB: |
{26} |
| ID: |
{23} |
| Group: |
{24} |
|
|
|
Account
|
| {25} |
| {27} |
| {28} |
| {29} |
| {30} |
|
|