CURRENT SYMPTOMS: (select all that apply)
Add new row
PAST MEDICAL/SURGICAL HISTORY: (select all that apply)
PAST SURGICAL HISTORY: (select all that apply)
Please list other medications you are taking (include "over-the-counter' medicine and doses)
Add Additional Medications
Does anyone in YOUR FAMILY have the following illnesses? Please write in the specific relationship of a family member, i.e. Mother, maternal aunt, paternal uncle, sister.
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of her/his staff responsible for any errors or omissions that I may have made in the completion of this form.
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