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Patient's Information
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First Name
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Last Name
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DOB
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Gender
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DOS
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Provider
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Basic Intake
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Basic
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Weight
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Height
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Activity Level
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Systolic Blood Pressure
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Diastolic Blood Pressure
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Pulse
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Temperature
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Method of Taking Temp
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Waist
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O2 Saturation
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Hip
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Relationships
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Marital
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Childhood Trauma?
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Sexual abuse as a child?
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Physically abused as a child?
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Occupation
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Own money management
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Maintains contact with family
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Maintains contact with friends
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Light housekeeping (dishwashing, dusting, etc)
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Heavy housekeeping (laundry, vacuum, etc)
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Shopping (groceries, clothing, etc)
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Housekeeping tasks
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Year start smoking
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Year quit
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Pack per day
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Even used other tobacco products
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MH & Cognition
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Stress
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New Field
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Medical History
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Medication History
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Allergies
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Nutrition Intake
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Physical Function
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MSQ
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