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          Patient Info  /  Medical History  /  Treatment  /  Progress Notes
The Patient Info page is under construction. You won't see these pages any more later on anyway. If you fill one in for fun, I will receive it.
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Patient Info Data

  Data Entry Person

  Today's Date         


   Last    First    MI

   SSN    Patient #

   DOB           Height    Weight

   Admission Date       (if applicable)

    Race     Gender    Language

   Address

    City     State     Zip

   Home Tel.    Work Tel.

    E-mail Address

    Marital Status    Employed?

   Occupation    Employer/Income

  Emergency Contact     Type?

   Contact Telephone



   

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The Medical History page is under construction. You won't see these pages any more later on anyway. If you fill one in for fun, I will receive it.