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NEW PATIENT HEALTH QUESTIONNAIRE DATE: / / Name: Gender: M / Date of Birth: Age: Referring Doctor: REASON(S) FOR VISIT 1. 2. 3. 4. 5. 6. Chest Pain 7. Heart Murmur Shortness of Breath 8. Dizziness
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The information that must be reported typically includes personal identification details, financial data, applicable deductions, and any additional information required by the filing entity.
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