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PCP name
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Reason for visit
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HPI
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Age
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Medical conditions
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other medical conditions.
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Telemedicine appointment today for follow up.
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She/He/They
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CAD
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Year of Diagnosis
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Treatment.
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Comments
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MI
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Year of Diagnosis
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Treatment.
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Comments
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Seizures
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Year of Diagnosis
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Treatment.
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Comments
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Cerebral Infarction/TIA/Stroke
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Year of Diagnosis
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Treatment.
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Comments
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Migraines
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Year of Diagnosis
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Treatment.
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Comments
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Hypertension
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Year of Diagnosis
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Treatment.
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Comments
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Hyperlipidemia
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Year of Diagnosis
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Treatment.
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Comments
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PCOS
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Year of Diagnosis.
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Menarche
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PCOS History
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Treatment.
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Comments
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Pre-diabetes
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Year of Diagnosis
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Treatment.
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Comments
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Type I Diabetes
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Year of Diagnosis
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Treatment.
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Complications
• • •
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Comments
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Type II Diabetes
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Year of Diagnosis
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Treatment.
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Complications
• • •
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Comments
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MASLD/Liver Disease
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Year of Diagnosis
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Treatment
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Comments
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Gallbladder Disease
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Year of Diagnosis.
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Treatment.
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Comments
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GERD
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Year of Diagnosis
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Treatment.
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Comments
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Bowel Disease
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Type
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Year of Diagnosis.
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Treatment.
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Comments
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Pancreatitis
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Year of Diagnosis.
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Treatment.
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Comments
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Kidney Disease
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Stage
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Year of Diagnosis.
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Treatment.
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Comments
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Nepholithiasis
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Year of Diagnosis.
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Treatment.
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Comments
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COPD
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Year of Diagnosis
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Treatment.
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Comments
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Asthma
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Year of Diagnosis
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Treatment.
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Comments
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OSA history/Screen
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Year of sleep study
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Year of Diagnosis
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Weight at diagnosis
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Treatment
• • •
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OSA Comments
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Anemia
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Year of Diagnosis
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Treatment.
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Comments
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Osteoporosis
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Year of Diagnosis
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Treatment.
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Comments
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Rheumatoid Arthritis
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Year of Diagnosis
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Treatment.
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Comments
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Osteoarthritis
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Year of Diagnosis
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Treatment.
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Comments
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Gout
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Year of Diagnosis
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Treatment.
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Comments
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Hypothyroidism
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Year of Diagnosis
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Treatment.
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Comments
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Hyperthyroidism
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Year of Diagnosis
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Treatment.
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Comments
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Thyroid cancer
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Type
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Year of Diagnosis
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Treatment.
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Comments
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Glaucoma
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Year of Diagnosis
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Treatment.
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Comments
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Cancer
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Type
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Year of Diagnosis
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Treatment.
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Comments
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Chronic Pain
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Type
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Year of Diagnosis
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Comments
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Treatment.
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Depression
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Year of Diagnosis
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Treatment.
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Comments
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Anxiety
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Year of Diagnosis
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Treatment.
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Comments
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Bipolar Disorder
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Year of Diagnosis
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Treatment.
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Comments
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Insomnia
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Year of Diagnosis
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Past treatment
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Current Treatment.
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Comments
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Other Mental Health Disease
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Type
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Year of Diagnosis
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Treatment.
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Comments
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Substance Abuse Hx
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Type
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Year of Diagnosis.
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Comments
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Treatment.
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Binge Eating Disorder
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Year of Diagnosis
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Treatment.
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Comments
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Anorexia Nervosa
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Year of Diagnosis
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Treatment.
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Comments
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Bulimia Nervosa
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Year of Diagnosis
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Treatment.
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Comments
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MK/Injury History
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MK/Injury history
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Location/Region
• • •
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Quality
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Severity / Intensity
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Duration
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Onset/Timing
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Context
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Modifying Factors
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Associated Symptoms
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Previous Treatment
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Other Medical Conditions
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Medical Condition 1
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Comment
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Medical Condition 2
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Comment
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Medical Condition 3
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Comment
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