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NAME: DATE: / / Age Sex Race Marital Status Pertinent changes in condition: NEW MEDICATION/ALLERGIES: PHYSICAL EXAM: GEN: BP / TEMP HR RESP Normal Abnormal Normal AbnormalHEENT / MOUTH / CARD / NECK
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The purpose is to gather demographic data and personal details for tracking, research, analysis, and decision-making purposes.
The information to be reported includes the individual's full name, date of birth, age, gender, race, and marital status.
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