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Family History
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If Other, Please Specify
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Sexual Activity
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Social
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Habits:
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Medical History
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If Other, Please Specify
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Activity Level
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MENS- Pertinent Medical/ Surgical History
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What Cancer (type) and Year if applicable:
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MENS- Birth Control Method:
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If Other, Please Specify
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WOMENS- Pertinent Medical/ Surgical History
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WOMENS- Birth Control Method:
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If Other, Please Specify
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