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Personal History & Evaluation of Patient Health

    Patient Information:
    Name:
    Date of Birth:
    Gender:
    Contact Number:
    Email:

    Reason for Visit:

    Past Medical History:
    Select any common diseases you have had:
    DiabetesHypertensionHeart DiseaseAsthmaCancerArthritisThyroid DisordersStrokeChronic Kidney DiseaseCOPDOsteoporosisAnemiaHepatitisMental Health DisordersAutoimmune DiseasesOther

    Marital Status:

    Personal Habits:
    Smoking: YesNo
    Drinking: YesNo
    Other Substances Used:

    Past Operations:
    1.
    2.
    3.

    Serious Injuries:
    1.
    2.
    3.

    Hospitalizations:
    1.
    2.
    3.

    Urgent Care/ER Visits:
    1.
    2.
    3.

    Radiation Treatments:
    1.
    2.
    3.

    Family History:
    (Fill in "Health," "Age," and check if "Deceased")
    Father: Yes
    Mother: Yes
    Sister(s): Yes
    Brother(s): Yes
    Wife/Husband: Yes
    Daughter(s)/Son(s): Yes

    Body System Review:
    Have you experienced any of the following symptoms in the last 3 months constantly, more than 2-3 times a week?
    Skin: RashesItchingDrynessOther
    Eyes: Blurred VisionRednessDrynessOther
    Nose and Throat: CongestionSore ThroatNosebleedsOther
    Breasts: LumpsPainNipple DischargeOther
    Musculoskeletal: Joint PainMuscle WeaknessBack PainOther
    Digestive: NauseaVomitingDiarrheaOther
    Genitourinary: Frequent UrinationPainful UrinationBlood in UrineOther
    Endocrine: Excessive ThirstExcessive HungerWeight FluctuationsOther
    Neurologic: HeadachesDizzinessNumbnessOther
    General: FatigueFeverWeight LossOther
    Heart and Lung: Chest PainShortness of BreathCoughOther

    Past Medications and Dosage:
    1.
    2.
    3.

    Medical Allergies:
    1.
    2.
    3.

    Other Comments:

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