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Allergies

Past or Current Medical History

Past Surgical History

Pharmacy

Past Family Medical History
FatherMotherBrother(s)Sister(s)
Thyroid cancer
Head/neck cancer
Cancer, Other:
Asthma/Allergies
Hearing loss
Diabetes
Heart Disease
Bleeding Disorders
High Blood Pressure
Stroke, Other:

Constitutional Symptoms

Skin

Eyes

Ears/Nose/Mouth/Throat

Cardiovascular

Pulmonary

Gastrointestinal

Genitourinary

Musculoskeletal

Neurological

Endocrine

Psychiatric

Hematologic

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