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Past Medical/Surgical History
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Past Medical History
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Additional Past Medical History Comments (optional)
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Past Surgical History
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Additional Surgical History Comments (optional)
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Family History
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Family history reviewed and normal?
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If "No", list abnormal Family History
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Social History
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Substance Abuse History
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Drinking and smoking history
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Employment Status
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If employed, list job title or description
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Job Requirements
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Comments on Social History (optional)
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