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Patient Information
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Height
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Weight
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Blood Pressure
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Temperature
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Current Medications
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Surgery/Past Medical History
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Symptoms
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Female Only
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Hysterectomy
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Ovaries
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Date of Last Pap
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Date of Last Mammogram
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Normal
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Labs
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Estradiol
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Testosterone
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Free Testosterone
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PSA
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Vitamin D
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TSH
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Free T3
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Total T4
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TPO
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CBC
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Chem Panel
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LDL
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HDL
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Triglycerides
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Progesterone
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B-12
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GFR
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FSH
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Plan
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Testosterone
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Testosterone Lot Numbers
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Hip
• • •
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Progesterone
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Anastrozole
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Vitamin ADK or D3
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Thyroid
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Iodine
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Probiotic
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Omega
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Signature
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Attending Staff
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Attending
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