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Patient InformationLast Name: First Name: Date of Birth: Age: Sex: Male / Female SSN: Street Address:City: State: Zip Code: County: Preferred Phone #: 2nd Phone #: Email: Marital Status (Circle One): Single / Married / Divorced / Widowed / PartnerSmoker (Circle One): Current / Former / Never Chew Tobacco: Current / Former / NeverDate Started: Date Stopped: Advance Directive: Yes / No If Yes Type/s: Primary Language: Race: Hispanic (Circle One): Y / NPatient’s Employer: Employer Address: Employer Phone #: Spouse’s Info:Name: Date of Birth: Address (if different): Primary Phone (if different): 2nd Phone: Emergency Contact InformationName: Date of Birth: Address (if different): Primary Phone (if different): 2nd Phone: Parent Information (If Patient is a Minor)Parent or Legal Guardian Name: Date of Birth: SSN: Address (if different): Primary Phone (if different): 2nd Phone: Employer Name: Employer Address: Employer Phone #: Parent or Legal Guardian Name: Date of Birth: SSN: Address (if different): Primary Phone (if different): 2nd Phone: Employer Name: Employer Address: Employer Phone #: ................
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