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List all hospitalizations and surgeries List all medication allergies if any Current Medication List include dosage and how many tablets do you take a day Name and Phone number of Primary care Doctor Date of last Physical with PCP Date of last eye exam Date of last Bone Density Date of last Pap smear female Date of last Mammogram Date of last Colonoscopy Date of last Tuberculosis test Date of last Flu vaccine Social History Have you ever smoked Yes. No Check below Do you smoke Smoker Some...
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