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    Tobacco Use:
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    Cancer

    Cancer?
    YesNo
    Last Treatment Rec'd (mm/dd/yy)
    Diagnosis Date (mm/dd/yy)

    Type - Treatment - Additional Details

     

    Diabetes

    Diabetes?
    YesNo
    Insulin Dependent?
    YesNo
    Number of Units
    A1C Level

     

    Heart Disease

    Bypass
    YesNo
    Surgery Date
    [datetime bypass-date date-format:mm/dd/yy time-format:HH:mm first-day:0 change-month change-year]
    Surgery Date 2
    [datetime bypass-date2 date-format:mm/dd/yy time-format:HH:mm first-day:0 change-month change-year]
    Stents/Angioplasty
    YesNo
    Surgery Date
    [datetime stent-date date-format:mm/dd/yy time-format:HH:mm first-day:0 change-month change-year]
    Surgery Date 2
    [datetime stent-date2 date-format:mm/dd/yy time-format:HH:mm first-day:0 change-month change-year]
    Valve Replacement(s)
    YesNo
    Surgery Date
    [datetime valve-date date-format:mm/dd/yy time-format:HH:mm first-day:0 change-month change-year]
    Surgery Date 2
    [datetime valve-date2 date-format:mm/dd/yy time-format:HH:mm first-day:0 change-month change-year]
    Pacemaker/Defibrillator
    YesNo
    Surgery Date
    [datetime pacemaker-date date-format:mm/dd/yy time-format:HH:mm first-day:0 change-month change-year]
    Surgery Date 2
    [datetime pacemaker-date2 date-format:mm/dd/yy time-format:HH:mm first-day:0 change-month change-year]

     

    673 E. Cherry Lane | PO Box 64477 Souderton, PA 18964 | Phone: 215-723-3044 or 800-872-3044 | Fax: 215-723-8036
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