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HEALTH HISTORY
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Today's Date:
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Salutation:
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Patient's Full Name:
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Address1:
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Address2:
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City:
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State:
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Zip:
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Home Phone:
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Work Phone:
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Patient's Age:
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Date of Birth:
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Gender:
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Height:
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Weight:
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Referring Physician:
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Family Physician:
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Briefly describe why you are here to see the doctor today:
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When did your problems/symptoms first appear:
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MEDICAL HISTORY |
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What significant illnesses or conditions have you had?
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What previous operations have you had?
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What medications are you currently taking?
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Please list any medications you are allergic to:
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MAJOR ILLNESS/DISEASE OF FAMILY MEMBERS |
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What illnesses or diseases have your mother had?
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What illnesses or diseases have your father had?
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What illnesses or diseases have your sisters/brothers had?
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What illnesses or diseases have your grandparents had?
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SOCIAL HISTORY
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Do you consume alcohol?
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If so, how much do you consume on average per week?
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Do you smoke cigarettes?
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Do you chew tobacco?
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Do you smoke a pipe or cigars?
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Do you dip snuff?
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How much tobacco do you consume on average per day?
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How long have you used tobacco?
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