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Dr.
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Date
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radiation therapy to the
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|
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patient noticed a ____
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in/on___
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approximately___ ago
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There was/was not
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associated ____
• • •
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Any comments
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You saw the patient and obtained a biopsy on __
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showing___
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Past Skin Cancer
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Past Sun exposure
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Present Sun exposure
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Problem List (Past Medical History) is positive
• • •
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If other, please specify
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