IDENTIFYING INFORMATION
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Patient Sex
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Marital Status
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Patient arrived with
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Accompanied (By Whom)
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Patient Living
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Patient lives with whom explain
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Patient Employment Status
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Physical Barriers to Treatment
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Physical Barriers Comments
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Specific Barriers to Treatment
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Specific Barriers Others
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Patient Current Medications
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Medication Instruction
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CURRENT PROVIDERS
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PCP
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Specialists
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CURRENT SYMPTOM CHECKER
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CURRENT SYMPTOM CHECKER
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PAST MEDICAL HISTORY
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Past Medical Conditions Include
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Any other medical problem
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Patient Hospitalized
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Patient Hospitalised Where
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When patient hospitalised
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Medication History
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Non-Pharmacological Therapies
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Laboratory Tests
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Imaging Studies
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