1. Age (if alive)
5. Heart Issues
10. Nervous Breakdown
11. Asthma, hives, hayfever
12. Blood disease
13. Age (at death)
14. Cause of death
Please select the symptoms that apply to why you are being seen by us today:
Please list all Allergies (i.e. medications, foods, household products, etc)
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Please list ALL surgeries AND hospitalizations:
Please list ALL diagnostic/radiological tests and WHY they were done:
Please list ALL medications/supplements you take:
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