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Medical History
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Past Medical History
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Past Medical History comments
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Cardiac Disorder/Event
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When?
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Past Surgical History
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Comments
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Family History
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Mother
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Comments
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Father
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Comments
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Sibling
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Comments
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Grandmother
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Comments
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Grandfather
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Comments
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Social History
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Tobacco Use
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Quit Smoking Date
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PPD
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number of years smoked
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Marital Status
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Employment
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Education
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Alcohol
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Drug use
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Caffeine
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Comments
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