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Past Medical History Freewrite
|
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Past Surgical History Freewrite
|
|
|
PCP
|
Date of last PE
|
|
|
|
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Family History (Lipedema)
|
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Family History Comments
|
Family Members with Lipedema
• • •
|
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Social History
|
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Marital Status
• • •
|
|
|
Where does patient live?
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Occupation
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Caffeine
|
|
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Alcohol
|
Comments
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Smoking
|
|
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Other substances
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