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Past Medical History
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Past Surgical History
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Childhood Illnesses
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Childhood Immunizations
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Adult Immunizations
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Date of last PE
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PCP
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PCP Contact Information
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Family History
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Father's Medical History
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Mother's Medical History
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Sibling(s) Medical History
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Grandparent's Medical History
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Children's Medical History
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Social History
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Marital Status
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Living Arrangements
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Occupation
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Social History
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Do you smoke now?
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Did you smoke in the past?
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Caffeine
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Comments
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Alcohol
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Comments
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Other substances
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Lifestyle
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Do you Exercise?
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If yes, how many days per week?
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How many minutes?
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What type of exercise do you do?
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Other hobbies/ recreational activities
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How stressed are you? (scale 1-5)
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SLEEP
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Usual Bedtime
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Usual Rising time
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How well do you sleep
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Sleep Comments
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