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ANAMNESIS

PERSONALDATA

JuanaDelaCruzis18yearsoldandbornonApril23,1997atVeteransMemorial
MedicalCenter,QuezonCity.Sheissingleandcurrentlylivingat#28TanguileSt.,Brgy.
VeteransVillage,Project7,QuezonCity.Shewasaccompaniedbyhermotherattheclinicfor
consultation.
CHIEFCOMPLAINT
Client:

..

Mother:

..

HISTORYOFPRESENTILLNESS
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PERSONALHISTORY
PRENATALDATA

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FIRSTYEAROFLIFEANDINFANT

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TWOTOTHREEYEARSOFLIFE
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THREETOFIVEYEARSUPTOPUBERTY

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EDUCATIONALHISTORY

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OCCUPATIONALHISTORY

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HOMEENVIRONMENT
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SOCIALRELATIONSHIPS

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FINDINGSATISFACTORYOUTLETSANDINTERESTS

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SEXUALLIFE

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RELIGIOUSACTIVITIES

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BEHAVIORHISTORY

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LATENCYPERIOD

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PUBERTYANDADOLESCENCE

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FAMILYHISTORY

FATHER

(paragraph)

MOTHER

(paragraph)

IMMEDIATEMEMBERSOFTHEFAMILY

(paragraph)

OTHERRELATIVES

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OTHERDATA

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HOMEANDENVIRONMENTALCONDITIONSANDFACILITIES

(paragraph)

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