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Past Medical History
• • •
|
PMH comments
|
|
Past Surgical History
• • •
|
Past Surgical History Comments
|
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Family Hx Noncontributory
|
|
|
Family History
|
comments
|
|
Father's MH
• • •
|
comments
|
|
Mother's MH
• • •
|
Comments
|
|
Sibling(s)' MH
• • •
|
Comments
|
|
Children(s)' MH
• • •
|
Comments
|
|
|
|
|
Social History
|
Social Hx comments
|
|
Marital Status
• • •
|
comments
|
|
Living Arrangements
• • •
|
Living Arrangements Comments
|
|
Functional History
• • •
|
|
|
Occupation
|
|
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Does the patient smoke?
|
Smoking Hx
• • •
|
|
|
Tobacco Comments
|
|
Does the patient drink alcohol?
|
Alcohol Hx:
• • •
|
|
|
ETOH Comments
|
|
Does the patient use drugs?
|
Drugs Comments
|
|
NKDA
|
Allergies (see list)
|
|
Allergies
|
|
