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I have the following doctor/s on my health care team:
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Which specialists do you see?
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Who referred you?
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Important Things About Me
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I am:
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How many people live in your home?
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Your ethnic backgroung (Checkl all that apply)
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What level of schooling have you completed?
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Are you current working?
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If working, what is your occupation?
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Is your job:
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When do you work?
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My Health:
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Have you ever been told you have Diabetes?
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If yes, what type of Diabetes do you have?
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Have you ever been diagnosed with other health conditions? (Check all that apply)
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Any food or medicine allergies? If so, please list:
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List all of the medicines and vitamins/supplements you are takig
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Have you had any surgies in the past?
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Yes, what kind?
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