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2066925-952500Patient Name______________________________________________Date of Birth_____/_____/_____Address______________________________________________________________________________City_________________________State___________Zip Code_____________SSN#______-_____-_____Phone#_________________Email_________________________________________________________Drug Allergies: Medication name and reaction____________________________________________________________________________________________________________________________________Medical (Check any of the following medical problems YOU have or are currently being treated for)__Allergies__Blood Clots__Gall Bladder Disease__Irritable Bowel Disease__Anemia__Cancer_________________Gerd/Acid Reflux__Myocardial Infarction__Angina__Cholesterol Elevated__Glaucoma__Osteoporosis__Anxiety__Congestive Heart Failure__Gout__Renal Disease__Arthritis__COPD__Headaches/Migraines__Seizure Disorder__Asthma__Coronary Artery Disease__Heart Valve Disorder__Stroke__A Fibrillation__Dementia__Hepatitis/Liver Disease__TB__Back Problem__Depression__HIV__Thyroid Disease__Benign Prostatic__Diabetes__HypertensionOther_________________Surgical Procedure__AAA Repair__CABG/Heart Bypass__ Hernia Repair__Lasik__Angioplasty__Cardiac Pacemaker__Hip Surgery__Mastectomy__Aortic Aneurysm__Cataract Extraction__Hysterectomy__ORIFF (Fracture)__Appendectomy__Cholecystectomy__Knee Surgery__Mastectomy__Arthroscopy__Colectomy__Pacemaker__Thyroidectomy__Back Surgery__Colostomy__Prostate Biopsy__Tonsillectomy__Blood Transfusion__Gall Bladder__Shoulder Surgery__Tubal Ligation__Breast Augment/Reduction__Gastric Banding__Sinuses surgery__Vasectomy__C-Section__Heart Valve__SplenectomyOther________________Immunization (Please write date or year of last vaccine)Flu VaccineTdap/TetanusPneumonia/Prevnar 13Pneumonia/Pneumovax 23Hepatitis AShingrix/ZostavaxPatient Name______________________________________________Date of Birth_____/_____/_____Family History (M for maternal/mother or P paternal/Father)__Alcoholism__Cardiovascular__Headache/Migraine__Obesity__Allergies__Cholesterol Elevated__Hepatitis__Osteoporosis__Alzheimer/Dementia__Congestive Heart Failure__Hearing Deficiency__Renal Failure__Anemia__COPD__HIV__Seizure Disorder__Anxiety__Depression__Hypertension__Stroke__Arthritis__Diabetes__Irritable Bowel__TB__Asthma__Genetic Disease__Learning Disability__Thyroid Disease__Benign Prostatic__Glaucoma__Mental IllnessOther_______________Cancer_______________Gout__Myocardia InfarctionHealth HabitsTobacco UseNever Age Started Age StoppedCigarette____ ____ ____Cigar/Pipe____ ____ ____Smokeless____ ____ ____E-Cigarette____ ____ ____Alcohol Use ____Rare ____Occasional ____DailyRecreational Drug Use:__________________________________________________________________Pharmacy Name and Adress:_____________________________________________________________List Current Medication (Including all vitamins and over the counter)MedicationDoseFrequency ................
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