42 Revision 01, September 2010
____________________________________________________________
____________________________________________________________
Please attach and list all relevant documentation (client file ,discharge report
etc.):
____________________________________________________________
____________________________________________________________
____________________________________________________________
Please include any other relevant client history , including any preexisting
medical condition(s):
____________________________________________________________
____________________________________________________________
____________________________________________________________
Relation to the Treatment:
Event Outcome:
Probable
Resolved
Possible
Improved
Probably not
Unchanged
Not
related
Worsened