Patient
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First Name
Middle Name
Last Name
Suffix
Birthday
Sex
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Male
Female
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Contact Information
Mobile Number
Phone Number
Email
Medical Information
Blood Type
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A+
A-
B+
B-
O+
O-
AB+
AB-
Disabilities
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Physical disability
Intellectual or learning disability
Psychiatric disability
Visual impairments
Hearing impairments
Neurological disability
Allergies
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Eggs
Milk
Peanuts
Tree nuts
Fish
Shellfish
Wheat
Soy
Pollen
Rubber
Chicken
Cat
Dog
Mold
Cockroach
Latex
Trees / Grass
Insect Sting
Allergy Others
Medical and Family History
Medical Histories
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Alcoholism
Alzheimer`s
Amblyopia
Anaphylaxis
Anemia
Aneurysm
Arrhythmia
Arthritis
Asthma
Biliary Tract Disease
Bipolar Disorder
Blindness
Cancer
Cataplexy
Cataracts
Chronic Pain
Cirrhosis
Collapsed Lung
Color Blindness
Congestive Heart Failure
COPD
Coronary Artery Disease
Crohn`s Disease
Cryptococcus
Cystic Fibrosis
Cytomegalovirus
Degenerative Arthritis
Depression
Dermatitis
Diabetes
Ectopic Pregnancy
Endometriosis
Epilepsy
Erectile Dysfunction
Gallstones
Glaucoma
Glomerulonephritis
Gout
Headaches
Hearing Impairment
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Hypertension
Hyperthyroidism
Hypothyroidism
Immune Deficiency
Infections (chronic)
Infertility
Insomnia
Ischemic Bowel Disease
Kidney Stones
Lupus
Lyme Disease
Macular Degeneration
MAI
Menopause
Multiple Sclerosis
Narcolepsy
Nephrotic Syndrome
Ocular Misalignment
Osteoporosis
Ovarian Cysts
Pancreatitis
Parkinson`s Disease
Peripheral Neuropathy
Pleural Effusion
Prostate Enlarged
Prostatitis (chronic)
Psoriasis
Pulmonary Embolism
Pulmonary Fibrosis
Reflux Esophagitis
Renal Failure
Retinal Detachment
Rheumatoid Arthritis
Sickle Cell Anemia
Sinusitis (chronic)
Sleep Apnea
Somnambulism
Spina Bifida
Stroke
Thalassemia
Tinnitus
Toxoplasmosis
Tuberculosis
Ulcers
Medical History Others
Family Medical Histories
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Alcoholism
Alzheimer`s
Amblyopia
Anaphylaxis
Anemia
Aneurysm
Arrhythmia
Arthritis
Asthma
Biliary Tract Disease
Bipolar Disorder
Blindness
Cancer
Cataplexy
Cataracts
Chronic Pain
Cirrhosis
Collapsed Lung
Color Blindness
Congestive Heart Failure
COPD
Coronary Artery Disease
Crohn`s Disease
Cryptococcus
Cystic Fibrosis
Cytomegalovirus
Degenerative Arthritis
Depression
Dermatitis
Diabetes
Ectopic Pregnancy
Endometriosis
Epilepsy
Erectile Dysfunction
Gallstones
Glaucoma
Glomerulonephritis
Gout
Headaches
Hearing Impairment
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Hypertension
Hyperthyroidism
Hypothyroidism
Immune Deficiency
Infections (chronic)
Infertility
Insomnia
Ischemic Bowel Disease
Kidney Stones
Lupus
Lyme Disease
Macular Degeneration
MAI
Menopause
Multiple Sclerosis
Narcolepsy
Nephrotic Syndrome
Ocular Misalignment
Osteoporosis
Ovarian Cysts
Pancreatitis
Parkinson`s Disease
Peripheral Neuropathy
Pleural Effusion
Prostate Enlarged
Prostatitis (chronic)
Psoriasis
Pulmonary Embolism
Pulmonary Fibrosis
Reflux Esophagitis
Renal Failure
Retinal Detachment
Rheumatoid Arthritis
Sickle Cell Anemia
Sinusitis (chronic)
Sleep Apnea
Somnambulism
Spina Bifida
Stroke
Thalassemia
Tinnitus
Toxoplasmosis
Tuberculosis
Ulcers
Family History Others
Smoker
Never
Occassional
Former
Light
Heavy
Alcohol Drinker
Never
Occassional
Former
Light
Heavy
Takes Illicit Drugs
No
Yes
Immunizations
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Adenovirus
Anthrax
Cholera
Diphtheria
Hepatitis A
Hepatitis B
Haemophilus influenzae type b (Hib)
Human Papillomavirus (HPV)
Seasonal Influenza (Flu)
Japanese Encephalitis
Measles
Meningococcal
Mumps
Pertussis
Pneumococcal
Polio
Rabies
Rotavirus
Rubella
Shingles
Smallpox
Tetanus
Tuberculosis
Typhoid Fever
Varicella
Yellow Fever
Immunization Others
Emergency Contact
Emergency Contact Name
Emergency Relationship
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Husband
Wife
Mother
Father
Sibling
Guardian
Child
Partner
Grandparent
Others
Emergency Phone Number
Emergency Mobile Number
Other Information
Civil Status
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Single
Married
Divorced
Separated
Widowed
Nationality
Religion
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Alliance of Bible Christian Communities
Baptist
Born Again Christian
Buddhism
Catholic
Christian
Church of God
Evangelical
Iglesia ni Cristo
Jehovahs Witness
Life Renewal Christian Ministry
Lutheran
Methodist
Aglipay
LDS-Mormons
Islam
Pentecostal
Protestant
Seventh Day Adventist
UCCP
Unknown
Wesleyan
Others
Highest Education
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Post Baccalaureate
College Graduate
College Undergraduate
Vocational
Highschool Graduate
Highschool Undergraduate
Elementary Graduate
Elementary Undergraduate
No Formal Education/No Schooling
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Occupation
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