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and modified

Patient name: Age: Sex: Date:

Medication input box:

MedStopper Link

Medical history input box:

Laboratory data:

BMI			BP			eGFR			Hb			Plt			LDL
Uric			ALT			FBS			A1C			Na			K
MMSE			PHQ9			GAD7			ACR			FEV1			FEVR

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