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Weight(lbs)
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Height(Inches)
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Women's Shoe size
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Men's Shoe size
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Past Medical History
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Past Medical History- Other
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HbA1C and date
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Past Surgical History
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Surgical History- Other
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Family History
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Family History Comments
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Occupation
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weightbearing status for pain?
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Smoker
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Comments
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Alcohol
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Comments
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Marital Status
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Living Arrangements
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Other scenarios
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PCP
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Date of last PCP visit
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Referred by
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Patient's diet
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Comments
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