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Medical History
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PCP
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Specialists
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Marital Status
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Work Status
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Occupation
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Past Medical History
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PMH Comments
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Past Surgical History
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PSH Comments
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Childhood Immunizations
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Comments
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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Other family history
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Social History
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Tobacco/smoking
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Smoking Comments
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Alcohol
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Alchohol Comments
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Non prescribed drug use
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Illicit Drug Use Comments
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Diet
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Diet Comments
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Does patient consume caffeine?
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Caffeine Comments
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Living Arrangements
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Living Arrangements Comments
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Does patient exercise?
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Exercise Comments
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Does patient sleep well?
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Sleep Comments
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Legal matters - Pt has:
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