PatientPop



Name: FORMTEXT ?????Past Medical History FORMCHECKBOX Arthritis FORMCHECKBOX Allergies/hay fever FORMCHECKBOX Asthma FORMCHECKBOX Alcoholism FORMCHECKBOX Alzheimer’s disease FORMCHECKBOX Autoimmune disease FORMCHECKBOX Blood pressure problems FORMCHECKBOX Bronchitis FORMCHECKBOX Cancer FORMCHECKBOX Chronic fatigue syndrome FORMCHECKBOX Carpal tunnel syndrome FORMCHECKBOX Cholesterol, elevated FORMCHECKBOX Circulatory problems FORMCHECKBOX Colitis FORMCHECKBOX Dental problems FORMCHECKBOX Depression FORMCHECKBOX Diabetes FORMCHECKBOX Diverticular disease FORMCHECKBOX Drug addiction FORMCHECKBOX Eating disorder FORMCHECKBOX Epilepsy FORMCHECKBOX Emphysema FORMCHECKBOX Eyes, ears, nose, throat problems FORMCHECKBOX Environmental sensitivities FORMCHECKBOX Fibromyalgia FORMCHECKBOX Food intolerance FORMCHECKBOX Gastroesophageal reflux disease FORMCHECKBOX Genetic disorder FORMCHECKBOX Glaucoma FORMCHECKBOX Gout FORMCHECKBOX Heart disease FORMCHECKBOX Infection, chronic FORMCHECKBOX Inflammatory bowel disease FORMCHECKBOX Irritable bowel syndrome FORMCHECKBOX Kidney or bladder disease FORMCHECKBOX Learning disabilities FORMCHECKBOX Liver or gallbladder disease (stones) FORMCHECKBOX Mental illness FORMCHECKBOX Mental retardation FORMCHECKBOX Migraine headaches FORMCHECKBOX Neurological problems (Parkinson’s, paralysis) FORMCHECKBOX Sinus problems FORMCHECKBOX Stroke FORMCHECKBOX Thyroid trouble FORMCHECKBOX Obesity FORMCHECKBOX Osteoporosis FORMCHECKBOX Pneumonia FORMCHECKBOX Sexually transmitted disease FORMCHECKBOX Skin problems FORMCHECKBOX Tuberculosis FORMCHECKBOX Ulcer FORMCHECKBOX Urinary tract infection FORMCHECKBOX Varicose veins FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Family History FORMCHECKBOX Arthritis FORMCHECKBOX Asthma FORMCHECKBOX Alcoholism FORMCHECKBOX Alzheimer’s disease FORMCHECKBOX Cancer FORMCHECKBOX Depression FORMCHECKBOX Diabetes FORMCHECKBOX Drug addiction FORMCHECKBOX Eating disorder FORMCHECKBOX Genetic disorder FORMCHECKBOX Glaucoma FORMCHECKBOX Heart disease FORMCHECKBOX Infertility FORMCHECKBOX Learning disabilities FORMCHECKBOX Mental illness FORMCHECKBOX Mental retardation FORMCHECKBOX Migraine headaches FORMCHECKBOX Neurological problems (Parkinson’s, paralysis) FORMCHECKBOX Obesity FORMCHECKBOX Osteoporosis FORMCHECKBOX Stroke FORMCHECKBOX Suicide FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ?????Health HabitsTobaccoY FORMCHECKBOX N FORMCHECKBOX Cigarettes FORMTEXT ?????Dip/Chew FORMTEXT ?????E-Cig FORMTEXT ?????Other FORMTEXT ?????AlcoholY FORMCHECKBOX N FORMCHECKBOX Daily? FORMTEXT ?????Socially? FORMTEXT ?????Drug UseY FORMCHECKBOX N FORMCHECKBOX Past? FORMTEXT ?????Current? FORMTEXT ????? ................
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