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Medical History
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Comments
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Childhood illnesses
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Comments
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Childhood Immunizations
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Comments
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Date of last PE
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PCP
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PCP Contact Information
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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Social History
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Marital Status
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Living Arrangements
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Potential Environmental Pathogen
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Sexual Hx
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Comments
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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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Patient's diet
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Symptom 1
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Symptom 1
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On a scale from 0-10, with 10 being the worst, select the number that best describes the symptom most of the time
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What percentage of the time you are awake do. you experience the above symptom at the above intensity?
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Did the symptom begin suddenly or gradually?
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When did the symptom begin?
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How did the symptom begin?
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What motions make the symptom worse? (Select all that apply)
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If other is selected, please specify:
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List 3 activities affected by the symptom, condition, or injury
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List 3 activities affected by the symptom, condition, or injury
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What makes the symptom better? (select all that apply)
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If other is selected, please specify:
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Describe the quality of the symptom (select all that apply)
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If other is selected, please specify:
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Does the symptom radiate to another part of the body?
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If yes is selected, where does the symptom radiate?
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Is the symptom worse at certain times of the day or night? (select all that apply)
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If other is selected, please specify:
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Have you received treatment for this condition and episode prior to today's visit?
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If other is selected, please specify:
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Symptom 2
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Symptom 2
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On a scale from 0-10, with 10 being the worst, select the number that best describes the symptom most of the time
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What percentage of the time you are awake do. you experience the above symptom at the above intensity?
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Did the symptom begin suddenly or gradually?
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When did the symptom begin?
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How did the symptom begin?
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What makes the symptom worse? (Select all that apply)
• • •
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If other is selected, please specify:
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List 3 activities affected by the symptom, condition, or injury
• • •
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List 3 activities affected by the symptom, condition, or injury
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What makes the symptom better? (select all that apply)
• • •
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If other is selected, please specify:
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Describe the quality of the symptom (select all that apply)
• • •
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If other is selected, please specify:
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Does the symptom radiate to another part of the body?
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If yes is selected, where does the symptom radiate?
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Is the symptom worse at certain times of the day or night? (select all that apply)
• • •
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If other is selected, please specify:
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Have you received treatment for this condition and episode prior to today's visit?
• • •
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If other is selected, please specify:
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Symptom 3
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Symptom 3
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On a scale from 0-10, with 10 being the worst, select the number that best describes the symptom most of the time
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What percentage of the time you are awake do. you experience the above symptom at the above intensity?
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Did the symptom begin suddenly or gradually?
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When did the symptom begin?
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How did the symptom begin?
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What makes the symptom worse? (Select all that apply)
• • •
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If other is selected, please specify:
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What makes the symptom better? (select all that apply)
• • •
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If other is selected, please specify:
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Describe the quality of the symptom (select all that apply)
• • •
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If other is selected, please specify:
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Does the symptom radiate to another part of the body?
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If yes is selected, where does the symptom radiate?
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Is the symptom worse at certain times of the day or night? (select all that apply)
• • •
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If other is selected, please specify:
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Have you received treatment for this condition and episode prior to today's visit?
• • •
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If other is selected, please specify:
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Symptom 4
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Symptom 4
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On a scale from 0-10, with 10 being the worst, select the number that best describes the symptom most of the time
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What percentage of the time you are awake do. you experience the above symptom at the above intensity?
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Did the symptom begin suddenly or gradually?
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When did the symptom begin?
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How did the symptom begin?
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What makes the symptom worse? (Select all that apply)
• • •
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If other is selected, please specify:
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What makes the symptom better? (select all that apply)
• • •
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If other is selected, please specify:
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Describe the quality of the symptom (select all that apply)
• • •
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If other is selected, please specify:
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Does the symptom radiate to another part of the body?
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If yes is selected, where does the symptom radiate?
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Is the symptom worse at certain times of the day or night? (select all that apply)
• • •
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If other is selected, please specify:
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Have you received treatment for this condition and episode prior to today's visit?
• • •
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If other is selected, please specify:
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Symptom 5
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Symptom 5
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On a scale from 0-10, with 10 being the worst, select the number that best describes the symptom most of the time
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What percentage of the time you are awake do. you experience the above symptom at the above intensity?
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Did the symptom begin suddenly or gradually?
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When did the symptom begin?
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How did the symptom begin?
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What makes the symptom worse? (Select all that apply)
• • •
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If other is selected, please specify:
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What makes the symptom better? (select all that apply)
• • •
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If other is selected, please specify:
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Describe the quality of the symptom (select all that apply)
• • •
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If other is selected, please specify:
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Does the symptom radiate to another part of the body?
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If yes is selected, where does the symptom radiate?
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Is the symptom worse at certain times of the day or night? (select all that apply)
• • •
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If other is selected, please specify:
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Have you received treatment for this condition and episode prior to today's visit?
• • •
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If other is selected, please specify:
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Symptom 6
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Symptom 6
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On a scale from 0-10, with 10 being the worst, select the number that best describes the symptom most of the time
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What percentage of the time you are awake do. you experience the above symptom at the above intensity?
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|
|
Did the symptom begin suddenly or gradually?
|
|
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When did the symptom begin?
|
|
|
How did the symptom begin?
|
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|
What makes the symptom worse? (Select all that apply)
• • •
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If other is selected, please specify:
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|
What makes the symptom better? (select all that apply)
• • •
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If other is selected, please specify:
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Describe the quality of the symptom (select all that apply)
• • •
|
If other is selected, please specify:
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|
Does the symptom radiate to another part of the body?
|
If yes is selected, where does the symptom radiate?
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|
Is the symptom worse at certain times of the day or night? (select all that apply)
• • •
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If other is selected, please specify:
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Have you received treatment for this condition and episode prior to today's visit?
• • •
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If other is selected, please specify:
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General [-]
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General
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General Comments
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Skin [-]
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Skin
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Skin Comments
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HEENT [-]
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HEENT
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HEENT Comments
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Neck [-]
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Neck
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Neck Comments
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Breasts [-]
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Breasts
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Breasts Comments
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Cardiovascular [-]
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Cardiovascular
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CV Comments
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Respiratory [-]
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Respiratory
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Resp Comments
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GI [-]
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GI
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GI Comments
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Urinary [-]
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Urinary
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Urinary Comments
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Genital (Male) [-]
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Genital (Male)
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Genital (Male) Comments
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Periph. Vasc. [-]
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Periph. Vasc.
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Periph. Vasc. Comments
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MSK [-]
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MSK
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MSK Comments
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Neurological [-]
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Neurological
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Neuro Comments
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Endocrine [-]
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Endocrine
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Endo Comments
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Psychiatric [-]
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Psychiatric
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Psychiatric Comments
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