PATIENT HEALTH HISTORY INFORMATION
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MEDication, ALLERGY and SURGICAL HISTORY
|Patient Name: DOB: |Today’s Date: |
|Primary Care Physician: |
|Medication |Dose |# per day |Physician |Reason taking medication |
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|ALLERGIES |
|Are you allergic to any of the following? Please list any other drug allergies: |
|Allergy: |Reaction: |Allergy: |Reaction: |
| Contrast Dye | | | |
| Iodine | | | |
| Betadine | | | |
| Shellfish | | No drug allergies | |
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|SURGICAL HISTORY |
|MO/YR |Procedure |Surgeon |
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Z:\Forms\Clinic\Meds Allergies and Surgical HX
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