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Why are you here (Present Illness)
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Reason for visit
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History of Present Illness
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Past Medical History
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No Birth Defects
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No Infancy Diseases
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No Childhood Diseases
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No Adolescent Diseases
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No Neurological Issues
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No Cardiovascular Issues
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No Pulmonary issues
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No GI Issues
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No GU Issues
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No Endo Issues
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No Bone or Joint Issues
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No Drug Allergies
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Surgical History
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Other - Additional Info
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Detailed Surgical History Note
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Smoker
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Drug
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Alcohol
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Additional Info
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Family History
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If yes, Additional Info
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Nervous Systems
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Other - Additional Info
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Cardiac Systems
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Other - Additional Info
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Pulmonary Systems
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Other - Additional Info
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Gastro Systems
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Other - Additional Info
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Endo Systems
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Other - Additional Info
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Genitourinary Systems
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Other - Additional Info
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Musculoskeletal
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Other - Additional Info
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Physical Exam
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General Appearance
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Additional Information
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Vital Signs
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Blood Pressure
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Heart Rate
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SP02 on Room Air
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SP02 on O2
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Temperature
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Hair: Normal
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If abnormal, enter additional information
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Scalp: Normal
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If abnormal, enter additional information
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Skull: Normal
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If abnormal, enter additional information
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Eyes: Normal
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If abnormal, enter additional information
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Ears: Normal
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If abnormal, enter additional information
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Nose: Normal
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If abnormal, enter additional information
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Throat: Normal
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If abnormal, enter additional information
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Neck: Normal
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If abnormal, enter additional information
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Thyroid: Normal
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If abnormal, enter additional information
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Supracla: Normal
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If abnormal, enter additional information
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Chest: Normal
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If abnormal, enter additional information
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Heart: Normal
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If abnormal, enter additional information
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Abdomen: Normal
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If abnormal, enter additional information
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Flanks: Normal
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If abnormal, enter additional information
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Upper Extremity: Normal
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If abnormal, enter additional information
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Lower Extremity: Normal
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If abnormal, enter additional information
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Skin: Normal
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If abnormal, enter additional information
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Neuro: Normal
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If abnormal, enter additional information
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Pulmonary Function Test
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Cardiovascular tests
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Radiological Data
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Sleep Studies
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Diagnosis
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Plan
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