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Occupation
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Where did you find us?
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Which specialists do you see?
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Other Specialist
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Who referred you?
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Want access to online portal?
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Anything special we need to know
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Current Weight
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Height
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Pregnancies
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Number Children
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Abortions
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Children ages (Separated by commas)
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Past Medical Illness
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Adult Medical illness comment
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Surgeries (Cirugias Previas)
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Other Surgeries Comment
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Problems with anesthesia
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Problems with anesthesia comment
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Childhood illnesses
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Childhood illnesses comment
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Tobacco (Anadir a Smoking Status)
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Tobacco Comment
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Caffeine (Cafe)
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Caffeine Comment
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Alcohol
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Alcohol Comment
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Mother Medical History
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Mother PMH comment
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Father Medical History
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Father PMH comment
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Siblings Medical History
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Siblings PMH Comment
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