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怡康復健專科診所 初診病歷表
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姓名
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性別
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男
女
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身分證字號:
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生日（範例：11/11/1911）
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MM
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DD
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YYYY
市內電話（範例：06-2986868）：
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手機
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住址
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是否有藥物過敏
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是
否
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呈上題，若您有
藥物過敏史，藥品名為：
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