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Birth date
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{mm/dd/yyyy}
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Name:-:Pt:^Patient:Set:
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Sex
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Race
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Ethnicity Computed
?
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Phone #
?
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Account #
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Social Security #
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Usual occupation
?
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Hx of Usual industry
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Emergency contact info Pnl
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Patient ID # or Provider Acct #
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Episode unique ID
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Emergency contact Name
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Emergency contact Address
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Emergency contact Phone #
|
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Emergency contact Relationship to pt
?
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