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Field #5 (copy)
Medical History
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Presenting Concerns
Have you experienced any of the following symptoms? (Check all that apply)
Fever
Chills
Cough
Shortness of breath
Nausea or vomiting
Diarrhea
Fatigue
Other (please specify)
Lifestyle and Social History
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What is your sexual orientation?
Heterosexual
Homosexual
Bisexual
Other
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Lifestyle and Social History
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Yes
No
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