Please correct the errors described below.

A. History of Illness

If no symptoms proceed to section B.

B. System Review

C. Family History

II. Past Medical History

A. Allergies

B. Please list any chronic medical conditions

C. Please list any surgeries:

E. Surgical

F. Dermatologic

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

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