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Get Patient Care Narrative/BLS Report Form

TO PATIENT LAST NAME FIRST M.I. AGE DATE OF BIRTH Gender ______________________________________________________________________________________________________________________________ PATIENT ADDRESS CITY STATE ZIP CHIEF COMPLAINT Medications Pt. States None Unknown ALLERGIES Pt. States None Unknown List: COPD Htn PULSE ____Normal Renal Failure Seizure Other________________________________ PUPILS Call Received ____Reactive L / R ___Voice ____Incoherent ____Moist ____Cyanotic .

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