Name ___________________________________                           date _____________

 

Signs & Symptoms ________________________________________________________________________

 

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Subjective _______________________________________________________________

 

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Objective _______________________________________________________________

 

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Initial Assesment and Plan __________________________________________________

 

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Overt Medical Concerns? __________________________________________________

 

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            Jonsquill Ministries

P. O. Box 752

Buchanan, Georgia 30113

171001-1