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Biometric Screening: Non-fasting
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Past Medical History
• • •
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Further details regarding above:
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Medications:
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Vitals, Height and Weight
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Height in inches
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Weight in lbs
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BMI
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HR
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BP
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O2 Saturation
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Test results
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HbA1C
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Total Cholesterol
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HDL
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Further explanation of results
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Interpretation of Results
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Explanation of need to contact MD on call:
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Name of examiner:
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