History and Physical

Please correct the errors described below.

Please list all medications you are currently taking (include prescriptions, over-the-counter meds and herbal supplements):

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Please list all prior surgeries:

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Please list all prior hospitalizations (other than for surgery):

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Social History

Do others depend upon you for their care?

Family History

Your Medical History

Have you ever had any of the following:

To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and the office staff of any changes in my medical status.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Current Problem

Where is the pain/problem located?

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