Primary Care Provider Patient Summary
Date:
Physician Information:
Physician Private Line:
Patient Information:
Thank you for looking after this patient. Here are some details you may find helpful:
MOST:
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Frailty Score:
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Ongoing Concerns and Medical History:
Last Visit information:
Last visit date:
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Last BP:
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Last weight:
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Last height:
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Last BMI:
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Relevant Lab Results:
Last Hgb:
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Last A1c:
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Last eGFR:
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Current Medications:
Other Medications:
Allergies:
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Social History
Substitute Decision Maker:
Risk Factors
Family History
Reminders
Subject: