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Name:DOB:Date:What is your occupation? What are your concerns for today's visit? Please answer the following to the best to your ability.1. What is your gender? MaleFemale2. How is your health? GoodFairPoor3.
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Your concerns refer to any issues or problems that are bothering you.
Anyone who has concerns or issues they need to address can file them.
To fill out your concerns, simply write down the issues or problems that are bothering you.
The purpose of filing your concerns is to address any issues or problems that are affecting you.
You must report any relevant details or information related to the concerns you have.
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