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Base on Health History GuidelinesHealth History FormActive, and Health History Worksheet, using RUA Sample Documentation to gather and organize information when conducting the health history of this patient (everything in red is important). 

I also attached a complete Example 2 as reference. 

Remember to include this reference into the work-cited page (add more references as required)

Jarvis, Carolyn. Physical Examination and Health Assessment, 7th Edition. Saunders, 022015. VitalBook file.