New Patient Medical Questionnaire
New Patient Medical Questionnaire Patient Name: DOB: PAST MEDICAL HISTORY Check for all that apply and indicate the year it was first identified PULMONARY: Asthma Pneumonia Emphysema / COPD GASTROINTESTINAL: Gastrointestinal Bleeding _ Ulcers Reflux (GERD) Liver Disease / Hepatitis RENAL/GENITOURINARY ................
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