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Copy of Copy of Patient Health Information
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Patient Health Information
Demographics
Problems
Allergies
Medications
Immunizations
Vital Signs
Family History
Social History
Procedures/Surgeries
Demographics
Patient Information
First Name
Last Name
M.I.
Date of Birth
Gender
-- None Selected --
Male
Female
Other
Unknown
Race
-- None Selected --
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
-- None Selected --
Hispanic or Latino
Not Hispanic or Latino
Unknown
Language
-- None Selected --
English
Spanish
Chinese
Japanese
Tagalog
French
Vietnamese
German
Korean
Russian
Arabic
Italian
Portuguese
French Creole
Other
Address
Address (Line 2)
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email
Communication Preference
-- None Selected --
Home Phone
Work Phone
E-mail
Mail
Other
Marital Status
-- None Selected --
Never Married
Married
Divorced
Separated
Annulled
Widowed
Domestic Partner
Social Security Number
Responsible Party Information
Same as patient
First Name
Last Name
M.I.
Insurance Information
Same as patient
Insurance Company Name
Group Number
Policy Number
Coverage Start Date
Coverage Lapse Date
Office Visit Copay
Insured's First Name
Insured's Last Name
M.I.
Insured's Date of Birth
Insured's Gender
-- None Selected --
Male
Female
Other
Unknown
Insured's Address
Insured's Address (Line 2)
Insured's City
Insured's State
Insured's Zip Code
Insured's Home Phone
Insured's Work Phone
Relationship to Patient
-- None Selected --
Child
Legal Guardian
Life Partner
Parent
Self
Spouse
Comments
Problems
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Allergies
Add New Allergy
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Medications
Add New Medication
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Immunizations
Add New Immunization
Comments
Vital Signs
Add New Vital Signs
Comments
Family History
Add New Family History
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Social History
Add New Social History
Comments
Procedures/Surgeries
Add New Procedure
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