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Get Standard Form 600 1997

__ year old ________with a _____day history of: (circle + response, cross out negatives) Allergies: Nausea vomiting: last episode___________ Abdominal pain fever diarrhea: # of stools in last 12 hours ____________ blood in stools lightheadedness when standing Meds: O: Labs: Additional History: Yes / No Have you received antibiotics in past month. If yes, NAME ________________ Yes / No Foreign travel in past month. If yes, COUNTRY _________________________ Yes / No If female, could you be.

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