Department of Oral maxillofacial surgery
Patient Code No *
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Patient Name
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Nationality
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Tribe
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Age
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Gender
Occupation
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Chief complaint
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History of chief complains
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Past medical history :
History of chronic illness
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Systemic review
CVS
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CNS
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RESP/SYS
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HEMAT
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GIT
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GIT
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ENDOCRINE
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MUSCUIOSKELETAL
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GENITURINARY
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Hospitalizations
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Past dental history
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Drug history :
Current medications
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Allergy
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Social history :
Marital status
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No. Of children
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Habits
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