A. History of Illness
B. System Review
C. Family 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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