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PATIENT INFORMATION SHEET - Primary Health

Crohn’s Disease Kidney Disease Pulmonary Embolism (PE) Other medical problems not listed above: _____ Surgical History: Please list all prior surgeries and approximate dates performed. SOCIAL / CULTURAL HISTORY: Education Level: ☐ Elementary ☐High School Vocational College Graduate / Professional

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  High, Sheet, Pulmonary, Pulmonary embolism, Embolism

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