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Past 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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Childhood illnesses
• • •
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Childhood Illnesses Freewrite
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Immunizations
• • •
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Other Comments
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Family History
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Father's Medical History
• • •
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Father's MH Freewrite
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Mother's Medical History
• • •
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Mother's MH Freewrite
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Daughter(s)' MH
• • •
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Daughter's MH Freewrite
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Sons(s)' Medical History
• • •
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Son's MH Freewrite
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Sibling(s)' Medical History
• • •
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Siblings MH Freewrite
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Paternal Grandmother's MH
• • •
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Paternal Grandfather's MH
• • •
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Maternal Grandmother's MH
• • •
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Maternal Grandfather's MH
• • •
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Social History
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Marital Status
• • •
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Living Arrangements
• • •
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Sexual Activity
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Occupation
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Caffeine
• • •
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Amount of Caffeine
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Alcohol
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Amount of Alcohol
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Other Substances
• • •
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Comments
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Diet
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Comments
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