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Review of Systems New Patient Full Name: ___Date of Birth: ___Today's Date: ___ Primary Care Doctor: ___Headache1. Constitutional Weight gain Weight lossY IN NY Y IN N NY Y Y Y Y Y Y IN N N N N N

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Demographic intake form (DIF) is a form used to collect demographic information such as age, gender, ethnicity, and income of individuals or participants.

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Organizations, agencies, or programs that receive funding or grants which require demographic data collection.

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Information such as age, gender, ethnicity, income, household size, and other relevant demographic data.

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