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(Describe overall health condition including any dietary limitations)
PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech)
MENTAL CONDITION (Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))
HEALTH HISTORY (List currently prescribed medications and major illnesses, surgery, accidents; specify whether hospitalized and length of hospitalization in
last 5 years)
SOCIAL FACTORS...
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