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NAME: NAME: NAME:

AGE: AGE: AGE:

ADD: ADD: ADD:

CC: CC: CC:

V/S V/S V/S

T T T

P P P

R R R

BP BP BP

O2 O2 O2

V/S V/S V/S

T T T

P P P

R R R

BP BP BP

O2 O2 O2

I&O: I&O I&O

MEDICATIONS: MEDICATION MEDICATION

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