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How did you find us?
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Want access to online portal?
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Do you use online scheduling?
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Illnesses you've had:
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Additional details
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Past hospitalizations?
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If yes, description and date
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Past surgeries?
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If yes, description and date
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Childhood illnesses
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Vaccinations you have had
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Family History
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Mother's medical history
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Additional details
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Father's medical history
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Additional details
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Maternal grandmother's medical history
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Additional details
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Maternal grandfather's medical history
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Additional details
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Paternal grandmother's medical history
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Additional details
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Paternal grandfather's medical history
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Additional details
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Sibling's/siblings' medical history
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Additional details
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Child's/children's medical history
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Additional details
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For Adults
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Occupation
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Marital Status
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Number of Children
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Typical daily meals
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How is your appetite?
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Soda
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How often?
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Caffeine
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What and how often?
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Alcohol
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How much?
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How much water do you drink?
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Other beverages
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Cigarettes
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How many?
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Smokeless tobacco
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How much?
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Other recreational substances
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Unusual Stressful Experience?
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Describe:
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How is your sleep?
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Hours you sleep?
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What do you do for exercise?
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Travelled outside the country?
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Which countries?
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Unusual birth history?
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Please describe
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Taken corticosteroids?
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More than 2 course of antibiotics?
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For Children
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Mother's health during pregnancy
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Mother's health during delivery
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Mother's health post-natally
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Medication used during pregnancy/delivery
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Vaginal birth?
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Medications given to child at birth
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Birth weight
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How many weeks gestation?
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Pregnancy/delivery complications
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Breast fed?
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Until what age?
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If formula-fed or supplemented, what kind?
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For Women
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Age of first period
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Date of last menstrual cycle
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Number of days in your monthly cycle
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How many days of flow?
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Color of flow?
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Are there clots?
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When do you have pain?
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Other symptoms of menstruation?
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Have you been diagnosed with:
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Are you currently pregnant?
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# of miscarriages
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# of live births
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# of abortions
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Method(s) of birth control
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GYN exam
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Date of last GYN exam
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PAP included
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Result
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History of any abnormal PAPs?
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Result
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Mammogram
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Date of last mammogram
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Mammogram result
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Bone density scan
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Date of last bone density scan
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Bone density result
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For Men
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Manual prostate exam
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Date of last manual exam
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Manual exam results
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PSA test
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Date of last PSA test
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PSA results
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Other symptoms
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Additional information
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