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Medical History Form
Gather more information about your patient to track their medical history.
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1
Full Name
*
This field is required.
First Name
Last Name
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2
Phone Number
*
This field is required.
1
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3
Check the conditions that apply to you or to any members of your immediate relatives:
*
This field is required.
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
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4
Check the symptoms that you're currently experiencing:
*
This field is required.
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
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5
Are you currently taking any medication?
*
This field is required.
Yes
No
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6
Do you have any medication allergies?
*
This field is required.
Yes
No
Not Sure
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7
What is your Gender?
*
This field is required.
Male
Female
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8
Do you use or do you have history of using tobacco?
*
This field is required.
Yes
No
No
Yes
No
2
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9
Do you use or do you have history of using illegal drugs?
*
This field is required.
Yes
No
No
Yes
No
3
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10
How often do you consume alcohol?
*
This field is required.
Daily
Weekly
Monthly
Occasionally
Never
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