Patient Intake/ Medical History

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PATIENT INFORMATION

EMERGENCY CONTACT

Please rank current and ongoing health problems by priority and fill in the other boxes as completely as possible:

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CONFIDENTIAL HEALTH HISTORY

Y= Yes (currently or in the past year)

P= Past

***If no history of the symptom, please leave blank.***

GENERAL

Condition/Symptom (indicate Y or P)

Comments (for doctor’s use only)

GASTROINTESTINAL

EYE/EAR/NOSE/THROAT

ENDOCRINE

CARDIOVASCULAR

PULMONARY

GENITOURINARY

NEUROLOGIC

MUSCULOSKELETAL

FEMALE REPRODUCTIVE

MALE REPRODUCTIVE

ACCIDENTS/TRAUMA

CHILDHOOD DISEASES

FAMILY HISTORY

IMAGING

Please list any imaging you have had done (x-rays, MRI, Bone scan, etc.)

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HOSPITALIZATIONS/SURGERIES

Please list dates and reasons:

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MEDICATIONS /SUPPLEMENTS

Please list ALL current prescription and non-prescriptions medications, dosage, and reasons:

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ALLERGIES

Please list all allergies (foods, medications, airborne):

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NUTRITIONAL STATUS

HABITS

EXERCISE

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