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First Name
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Date of Birth
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Sex
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Race / Ethnicity
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Height (Feet)
Height (Inches)
Weight (lbs)
BMI
Comorbidities
Asthma — J45
Chronic Kidney Disease — N18
Coronary Artery Disease — I25
Diabetes Mellitus Type 2 — E11
Hypertension — I10
Other comborbidiltes —
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Medication History
Amoxicillin
Atorvastatin
Ibuprofen
Lisinopril
medicine test
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Allergies
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Latex
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other allergy
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Smoking Status
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Prior Medical Treatments
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