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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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Past Surgical History Freewrite
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Last menstrual period
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Family History
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reviewed and considered noncontributory
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Father's MH
• • •
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If Cancer, please select
• • •
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Other, please specify
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Mother's MH
• • •
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If Cancer, please select
• • •
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Other, please specify
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Sibling(s)' MH
• • •
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If Cancer, please select
• • •
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Other, please specify
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Social History
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Do you use tobacco?
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If yes, please select the type
• • •
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Do you drink alcohol?
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If yes, how frequently
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Lives in______
• • •
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with who____
• • •
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If other, please mention
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Marital status
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Default template
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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 Wellness Exam/Visit
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Health Maintenance
• • •
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PCP Contact Information
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Other Providers
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Family History
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Comments
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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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Social History
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Marital Status
• • •
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Potential Environmental Pathogen
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Living Arrangements
• • •
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Comments
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Sexual Hx
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Occupation
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Comments
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Caffeine
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Comments
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Alcohol
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Tobacco History
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Patient's diet
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