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Past Medical Illness
• • •
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Past Medical illness
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Surgeries
• • •
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Past Surgeries Comment
|
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Birth History
• • •
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Birth History comment
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Social History Comments
|
|
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Tobacco
• • •
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Tobacco Comment
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Caffeine
• • •
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Caffeine Comment
|
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Alcohol
• • •
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Alcohol Comment
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Marital Status
• • •
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Marital Status Comment
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Occupation
|
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Family Hx
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Father PMH
• • •
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Father PMH comment
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Mother PMH
• • •
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Mother PMH comment
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Siblings PMH
• • •
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Siblings PMH Comment
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Relatives
• • •
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Relatives PMH comment
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