PATIENT HISTORY FORM - Dartmouth-Hitchcock
PLEASE CIRCLE ANY OF THE FOLLOWING IF YOU HAVE HAD THAT SYMPTOM OR FILL IN THE BLANK. Recent weight change Weakness of muscles. Fever Muscle pain or cramps. Fatigue Neck or back pain. Headaches Difficulty walking. Cancer or tumor. Chronic pain Rash or itching. Cholesterol problem. Frequent headaches ................
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