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PLEASE CIRCLE Your Past Medical History:Diabetes type:__________________________?????????????????????????????????????????????????????????High Blood Pressure????????????????????????????????????????? ??Thyroid disease ????????????????????????????????????????????????? ?Heart Disease____________________________ ??????????????????????????????????????????????? ????? Heart Murmur____________________________???????????????????? ????????????????????????????????? Elevated Cholesterol ??????????????????????????????????????????? Respiratory/lung disease______________________________????????????????????????????????????? Acid RefluxKidney Disease ______________________Anxiety / DepressionGlaucoma/eye disorder_____________________________ ????????????????????????????????????? Allergies____________________________????????????????????????????????????? ??? Cancer???Type________________________???????????????????????????????????????????????????????? Autoimmune Disease??type:?________________________Bleeding disorder type _____________________________??????????? ?????????????????????????? Other Medical Condition ________________________________________________________________________PLEASE CIRCLE Past surgical history:TonsillectomyAdenoidectomyEar tubesHysterectomyThyroidectomyEar surgery_________________________SeptoplastySinus surgery________________________Gallbladder removedAppendix removedHernia repairCancer surgery_______________________Cataracts removedC-sectionJoint surgery type:_________________________Spine surgery type: ________________________Angioplasty__________________________CABG _____________________________Other surgical procedures:____________________________________________________________________________________________________________________________________________________________________________________ Please CIRCLE symptoms you presently have :ConstitutionalChills Fatigue Weight loss/gain Daytime fatigue EyesEye pain Watery Itchy eyes Blurred vision Ears, Nose, Mouth, ThroatEar pain Ear itch Ear drainage Dizziness / Loss Of balance Loss of Hearing Ears ringing Ear fullness NosebleedsPost-nasal Drip Facial pain Sinus pressure Nasal congestion Loss of smell/taste Hoarseness Sore throat Dry Mouth/ThroatThroat clearing SnoringCardiovascularIrregular heart beats Chest pain RespiratoryCough Short of Breath Wheeze Coughing up blood GastrointestinalHeartburn Burping Trouble swallowing MusculoskeletalJoint pain Muscle aches SkinRash Itching Hives Change in skin NeurologicalHeadaches Fainting PsychiatricDepression Anxiety Hematologic/LymphaticSwollen glands Night sweats Bleeding disorder Clotting disorder Easy bruising Allergic/ImmunologicSneezing Itchy nose Itchy eyes ................
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