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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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Comments
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Date of last PE
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PCP
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PCP Contact Information
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Family History
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Father's medical history
• • •
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Comments
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Mother's medical history
• • •
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Comments
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Sibling medical history
• • •
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Comments
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Sibling medical history
• • •
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Comments
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Grandparent's medical history
• • •
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Comments
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Children(s)' medical history
• • •
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Comments
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Social History
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Marital Status
• • •
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Identifies as which sex
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Living Arrangements
• • •
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Who is present during exam
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Sexual Hx
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Comments
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Occupation
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Caffeine
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Comments
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Alcohol
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Comments
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Tobacoo use
• • •
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Pack Year history
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Substance use
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Comments
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Patient's diet
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