Patient Information:
Age: XX years
Gender: XXXX
Height: XXX cm (XX ft/XX ins)
Weight: XX.X kgs (XXX lbs)
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Blood Pressure: XXX/XX mmHg
Pulse Rate: XX/minute
Respiration: XX/min
Temperature: XX°C (XX.X°F)
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Chief Complaint: |
TYPE CC TEXT HERE |
| History of Chief Complaint: |
TYPE HCC TEXT HERE |
Dental History:
Medical History: :
Significant Findings:
Current Medications:
Allergies:
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TYPE DENTAL HISTORY TEXT HERE
TYPE MED HIST SIG FINDINGS HERE
TYPE CURRENT MEDS HERE
TYPE ALLERGIES HERE
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Social/Family History:
Significant Findings:
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TYPE SOCIAL HIST SIG FINDINGS HERE |
Clinical Examination:
Significant Findings:
Extraoral:
Intraoral:
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TYPE CLIN EXAM SIG FINDINGS HERE
TYPE EO FINDINGS HERE
TYPE IO FINDINGS HERE
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