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Which specialists do you see?
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Anything special we need to know
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Health History
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History of Present illness
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Location (Where is the pain/problem?)
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Chief Complaint
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Severity (How severe is the pain/problem on a scale of 1-10 with 10 being the most severe?)
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Duration (How long have you had this pain/ problem? When did it start?)
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Timing (Does the pain/problem occur at a specific time?)
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Context (Where were you at the onset of this pain/problem?)
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Associated Signs/Symptoms (What other associated problems have you been having?)
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Occupation
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Past Medical History
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Measles
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Anemia
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Back Trouble
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Hepatitis
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Mumps
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Bladder Infection
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High Blood Pressure
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Ulcer
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Chicken Pox
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Epilepsy
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Low Blood Pressure
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Kidney Disease
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Whooping Cough
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Migraine Headaches
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Hemorrhoids
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Thyroid Disease
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Scarlet Fever
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Tuberculosis
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Diphtheria
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Bleeding Tendency
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Asthma
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Diabetes
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Small pox
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Cancer
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Hives of Eczema
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If Yes, Please list
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Polio
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Pneumonia
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Rheumatic Fever
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AIDS & HIV
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Infectious Mono
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Glaucoma
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Hernia
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Arthritis
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Venereal Disease
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Bronchitis
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Mitral Valve Prolepses
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Blood or Plasma
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Stroke
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Seizures/epilepsy
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Allergies
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Transfusion
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Any Other Disease
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Pins/needles in hands/feet
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(Please List)
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Medication (include nonprescription)
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1. Previous Hospitalizations/Surgeries/Serious Illnesses
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When?
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Hospital, City, State
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Are you taking any medications (prescription or over the counter) for acid indigestion?
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if yes what type
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Patient Social History
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Use of Alcohol
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Use of Tobacco
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Use of Drugs
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If yes, Type/Frequency
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Excessive Exposure At home or at work to
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Family Medical History
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Father
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Disease
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If Deceased, Cause Of Death
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Mother
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Disease
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If Deceased, Cause Of Death
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Are You Married ?
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Do you have children
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Are you pregnant or could be pregnant ?
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Last mentrual cycle
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Please read below
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