PATIENT H&P FORM
FAMILY HISTORY PLEASE INDICATE WITH RELATIONSHIP (i.e. father): Do you know of any blood relatives who have or have had any of the following? Cancer Diabetes Epilepsy Heart Disease High Blood Pressure Psoriasis Congenital Problems Obesity Asthma Alcoholism TB Thyroid Problems Rheumatic Fever Rheumatoid Arthritis Stroke ... ................
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