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Medical History
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Past Medical History
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Past surgical Hx
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Date of last PE
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Specialists
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Family History
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Mother's Medical Hx
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Father's Medical Hx
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Paternal Grandparent's Medical Hx
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Maternal Grandparent's Medical Hx
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Sibling's Medical Hx
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Children(s) Medical Hx
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Social History
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Marital Status
• • •
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Occupation
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Caffeine
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Comments
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Alcohol
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Comments
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Other Substances
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Other substances
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