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Patient Name: DOB: MAN: Date of Service: Are you in any pain related to your visit today? (0 is no pain, 10 is horrible pain) CHIEF COMPLAINT (Why are you here to see Dermatology?) REVIEW OF SYSTEMS

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Are you in any refers to the declaration of any potential conflicts of interest or other relevant information.

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The individuals required to file are you in any are usually employees in positions that may present conflicts of interest.

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