• Medical History Questionnaire

  • Please fill out in blue or black ink only.

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  • MEDICAL HISTORY

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  • Family History

  • Please note any family history (parents, grandparents, siblings, children; living or deceased) of the following conditions:

  • SOCIAL HISTORY This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

  • REVIEW OF SYSTEMS: Do you currently or have you ever had any problems in the following areas?

  • CONSTITUTIONAL

  • INTEGUMENTARY(SKIN)

  • NEUROLOGICAL

  • EYES

     

  • ENDOCRINE

  • EARS, NOSE, MOUTH, THROAT

     

  • RESPIRATORY

  • Asthma Chronic Bronchitis Emphysema

  • VASCULAR/CARDIOVASCULAR

  • GASTROINTESTINAL

  • GENITOURINARY

  • BONES/JOINTS/HEMATOLOGIC

  • LYMPHATIC/HEMATOLOGIC

  • ALLERGIC/IMMUNOLOGIC

  • PSYCHIATRIC

  • Doctor's Signature Date

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  • Should be Empty: