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Patient Medical History And Questionnaire
** THE FOLLOWING INFORMATION ALTHOUGH OPTIONAL WILL BE INCLUDED ON YOUR PERSONAL HEALTH RECORD CD**
A GENERAL HEALTH QUESTIONS
I wear contact lenses       Yes   No                              I wear dentures     Yes    No
I wear a pacemaker         Yes   No
Do you smoke or use tobacco?                                   Yes   No
Have you ever applied for disability?                         Yes   No
If yes, for what condition              
Family History: Age: Diseases?
Mother Alive: Yes No
Father Alive: Yes No
Brother Alive: Yes No
Brother Alive: Yes No
Sister Alive: Yes No
Sister Alive: Yes No
B Medication & Herbal Supplements Dosage Daily Frequency
C List any surgical implants (if NONE, enter "NONE") Date
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D Any Medical Conditions & / or Treaments Date
Please include any Surgeries, Strokes, Coronaries etc...
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E MY PAST MEDICAL HISTORY - Have you "ever" been treated for:
Asthma Nervous Disorders Anorexia Nervosa Sexually Transm. Disease
Bronchitis Pneumonica Bulimia Allergies
Chronic Bronchitis Emphysema Liver Disorder Diabetes
Arthritis Tuberculosis Hepatitis Thyroid Disease
Gout Pleurisy Recurrent Indigestion Leukemia
Ulcer Shortness of Breath Stomach Disorder Endocrine(Glandular) Disd.
Colitis Persistent Cough Recurrent Diarrhea Anemia
Ileitis Persistent Hoarseness Intestinal Disd. / Bleeding Blood Disorder
Eye Disorders Chronic Respiratory Disd. Gall bladder Disorder Congenital Disorder
Ear Disorders High Blood Pressure Kidney Stones Recurrent Infections
Nose Disorders Rheumatic Fever Kidney Disorder Sciatica
Throat Disorders Hear Disorder Prostate Disorder Lameness
Back or Spine Disorders Heart Attack Bladder Disorder Cancer
Nerve Disorders Heart Murmur Reproductive Sys. Disd. Fibroids
Fainting Spells Healrt Palpitation Blood in Urine Skin Cancer
Dizziness Chest Pain Albumin in Urine Skin Disorder
Convulsions Blood Vessel Disorder Sugar in Urine Tumor
Paralysis Hemorrhoids Protein in Urine Lymph Gland Disorder
Stroke Diverticulitis Pus in Urine Mental Disorders
* Abbreviations: Sys. = System;  Disd. = Disorders;  Transm. = Transmitted    
F PHYSICIAN SPECIALIST INFORMATION
Specialist (physician)         
Specialty         
Telephone number                 Area Code                      Number    - 
Specialist (physician)         
Specialty         
Telephone number                 Area Code                      Number    - 
if add'l room is needed, go to "OTHER INFORMATION" section
G Immunizations / Other Information:
Use this space all immunization and / or medical information which you feel will be helpful in an emergency


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