Serenity GYN & Functional Medicine

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DEMOGRAPHICS

FINANCIAL INFORMATION

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Patient History Questionnaire

Review of Systems:

General:

Pulmonary:

Cardiac:

Infectious Disease:

Gynecologic/Urologic:

Psychiatric:

Blood/Lymph:

Head and Neck:

Eyes:

Gastrointestinal:

Skin:

Neurological:

Musculoskeletal:

Surgical History

Pap Smear/Mammogram History

Pregnancy History (All pregnancies)

Add a new row for another pregnancy

Family & Social History

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