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Medical History
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Past Medical History Freewrite
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Surgical History
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Additional Comments:
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FAMILY HEALTH HISTORY
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Father's Medical Health
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Comments
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Mother's Medical Health
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Comments
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Sibling(s) Medical Health
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Comments
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Grandparent's Medical Health
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Comments
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Children's Medical Health
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Comments
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CARDIOLOGY
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Have you EVER seen a Cardiologist?
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Patient Currently Seeing Cardiologist
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Provider and Location
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If Yes, what for?
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Date of Last EKG:
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Have You Ever Had Heart Surgery?
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Do You Have Any of the Following?
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If yes, when?
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Who Manages Your Heart Medications?
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SOCIAL HISTORY
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Smoking Status
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Smoking- How Much
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Has Smoked Since (Age or Year)
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Stopped Smoking (Age or Year)
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Do You Chew Tobacco?
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Comments
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Recreational Drug Use?
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Comments
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Alcohol
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Caffeine
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Exercise Level
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Hand Dominance
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Marital Status
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Do You Use Any of the Following?
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Living Situation
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Do you have someone to assist you, if surgery is needed?
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OTHER
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Do You Use Any Of The Following Devices?
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Comments
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Do You Have Any Loose Teeth?
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Do You Wear Dentures?
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If YES, is it a Partial?
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Do You Experience Nasea/Vomiting After Surgery?
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Have You Been Told You Are Difficult to Intubate?
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Do You Have Any Bleeding Disorders?
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Comments
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Have You Had Radiation to the Throat or Mouth?
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Comments
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MEDICATIONS
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Are You On Any Blood Thinners?
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Comments
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Have You Taken Any of The Following Medications in the Last 6 Months?
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Comments
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