NEW PATIENT MEDICAL INFORMATION

Date:____________________________________________

Name:______________________________________

Age:_______________________________________

Do you have any medical problems? ٱ High blood pressure

ٱ Diabetes

ٱ Asthma

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________________________________

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Have you had any surgeries? ٱ Appendix

ٱ Gall Bladder

ٱ Hysterectomy

Are you allergic to any medicines? ٱ Penicillin

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Please list any medicines you take: ________________________________

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Please list any hospitalizations: ________________________________

Do any diseases run in your family? ð Diabetes

ð High blood pressure

ð Heart problems

ð Cancer

ð TB

Do you smoke? (No/Yes) Drink? (No/Yes)

Why are you here today? ___________________________________________

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Please list any other symptoms or health concerns which you may be having: