Dr
Name of person responsible for this account:_____ ... Other Doctors seen for this problem (please list):_____ ACTIVITIES OF DAILY LIVING. Please circle the number to select the most appropriate statement. 0 = Able to function / 10 = Unable to function ... Osteoporosis. Pleurisy. Pneumonia. Polio. Psoriasis. Stroke. Thyroid Disorder ... ................
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