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Medical History
Name
First
Last
Phone
###
-
###
-
####
Check the conditions that apply to you or to any members of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorders
Epilepsy
Check the symptoms that you are currently experiencing:
Chest pain
Respiratory
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Are you currently taking any medication?
Yes
No
What medication are you currently taking?
Do you have any medication allergies?
Yes
No
What allergies do you have?
What is your gender?
Male
Female
Are you pregnant?
Yes
No
Do you use or do you have a history of tobacco use?
Yes
No
Do you use or do you have a history of illegal drugs use?
Yes
No
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
