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Medical History
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Past Medical History
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Past Surgical History
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Menstrual Hx/Birth Control/Hx Gestational DM
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PCP
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Family History
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Father's Med Hx
• • •
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Comments
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Mother's Med Hx
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Comments
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Sibling(s)' Med Hx
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Comments
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Grandparent's Med Hx
• • •
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Comments
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Comments
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Social History
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Marital Status
• • •
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Children
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Living Arrangements
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Smoking Hx
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Work out/Exercise Routine
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Comments
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Occupation
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Sleep
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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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Level of Stress
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