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PERSONAL MEDICAL AND SURGICAL HISTORY
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No new or updated medical or surgical history
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New Medical/Surgical History
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Medical /Surgical History
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Past Medical History (age 13 and older)
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Past Medical History additional
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Surgeries
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Past Surgical History
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Past Surgical History comments
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Childhood Illness or injuries
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Childhood illnesses
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Childhood Illness Comments
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Immunizations
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Immunizations
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Immunization Comments
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FAMILY MEDICAL HISTORY
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New family history to report or update
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No new family history to report or update
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Father
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Father
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Father Comments
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Mother
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Mother's
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Mother Comments
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Siblings
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Sibling Comments
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Sibling(s)'
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Grandparents
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Grandparent's
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Grandparent Comments
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Children
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Children(s)'
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Children comments
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SOCIAL HISTORY
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No updates to social history
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New social history
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Environmental risks
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Marital Status
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Living Arrangements
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Sexual Hx
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Occupation
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Substance Use
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Coffee, Alcohol, Substances - Please review each visit
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Caffeine use
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Alcohol Use
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Comment on substances
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Other Substances
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Labs
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Lab Comments
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Radiology
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Radiology Comments
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PT/OT Recommendations
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PT Recommendation Comments
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Home Health
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Home health comments
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Other referrals
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Other Referral Comments
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Education
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Education Comments
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General Instructions
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General Instruction Comments
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Procedures
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