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Chief Complaint
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Onset
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History of Present Illness
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Other providers
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Medications
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Supplements
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Surgical History
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Past Medical History
• • •
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Family History
• • •
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Vaccine History
• • •
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Social History
• • •
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Diet
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Food allergies/sensitivities
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Sleep pattern
• • •
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Energy
• • •
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Exercise
• • •
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ROS: Head
• • •
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ROS: Eyes
• • •
|
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ROS:Ears
• • •
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ROS: Nose
• • •
|
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ROS: Mouth/Throat
• • •
|
|
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ROS: Cardiovascular
• • •
|
|
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ROS: Respiratory
• • •
|
|
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ROS: Gastrointestinal
• • •
|
|
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ROS: Genitourinary
• • •
|
|
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ROS: Musculoskeletal
• • •
|
|
|
ROS:Dermatological
• • •
|
|
|
ROS: Neurological/Psychiatric
• • •
|
|
|
ROS: Infectious Diseases
• • •
|
|
|
ROS:Environmental
• • •
|
|
|
ROS: Other
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|
