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PAST MEDICAL HISTORY
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other medical problems
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SURGICAL HISTORY
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Complete list of surgeries
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FAMILY HISTORY
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Please select
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(-) heart disease
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(-) cancer
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SOCIAL HISTORY
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Does the patient smoke?
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If yes, please specify ppd
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Does the patient drink alcohol?
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If yes, please mention drinks per day/week
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Does the patient use drugs?
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Comments
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Occupation
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WorkStatus
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if disability, please mention
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Family
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number of children
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Medical History
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Comments
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Childhood illnesses
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Comments
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Childhood Immunizations
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Comments
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Date of last PE
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PCP
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PCP Contact Information
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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Social History
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Marital Status
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Living Arrangements
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Potential Environmental Pathogen
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Sexual Hx
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Comments
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Occupation
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Caffeine
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Comments
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Alcohol
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Comments
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Other substances
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Patient's diet
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