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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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Immunization Comments
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Adult Immunizations
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Flu Shot Date
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Date of last PE
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Pneumonia Shot Date
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PAP Smear
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Singles Shot Date
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Mammogram
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DEXA
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Colonoscopy
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Eye Exam
• • •
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Pregnancy
• • •
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FDLMP
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Family History
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Significant Yes/No
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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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Familial Cancers
• • •
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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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Sexual Orientation
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Comments
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Caffeine
• • •
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Comments
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Alcohol
• • •
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Comments
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Drugs
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Comments
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Diet
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Comments
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Spiritual Beliefs
• • •
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Comments
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Occupation
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Social History Freetext
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