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Past Medical History
• • •
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Past Medical Hx comment
|
|
Past Surgical History
• • •
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Past Surgeries Comment
|
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NKDA
|
Allergies Comments
|
|
No Meds
|
Meds Comments
|
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Social History Comments
|
|
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Tobacco
• • •
|
Tobacco Comment
|
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Alcohol
|
Alcohol Comment
|
|
Occupation
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Currently working
|
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Last day of work = accident
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Last day of work = other
|
|
Family PMH
• • •
|
Family PMH comment
|
