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Patient Medical History
Name
First
Last
Date
/
MM
/
DD
YYYY
Reason for Today's Visit
Check all that apply to you or your immediate family (parents, siblings, grandparents)
Asthma / Lung Problems
Cancer
Cardiac Disease
Diabetes
History of Back Pain
Hypertension
Psychiatric Disorders
Seizure Disorder
Stroke
Check all symptoms you are currently experiencing
Allergy
Cardiovascular
Chest Pain
Connective Tissue Disease
Diabetes Mellitus
Eating Disorder
Ear / Nose / Throat
Eye
Fever
Gastrointestinal
Genitourinary
Hemtalogical
Lymphatic
Musculoskeletal Pain
Neurological
Psychiatric
Respiratory
Skin
Weight Gain
Weight Loss
Please list any medication allergies that you have :
Please list any medications you are currently taking (and dosage if known) :
If you are a woman, are you currently pregnant, or is there a possibility that you are pregnant?
Yes
No
Are you currently using or do you have a history of tobacco use?
Yes
No
Are you currently using or do you have a history of illegal drug use?
Yes
No
Do you feel you are at risk for falls or falling injuries?
Yes
No
Please describe your alcohol consumption :
Daily
Weekly
Monthly
Occasionally
Rarely
Never
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