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510540010795File Number:_________020000File Number:_________ Patient Health Summary Clinic Name/Practitioner Name/Registration #Clinic Address/Clinic Telephone NumberPatient InformationFirst Name: Last Name:Middle Name:Telephone (Home/Mobile): Telephone (Business):Sex: M / F / OtherHome/Street Address: Apt #:Date of Birth: (DD/MM/YY)City: Province: Postal Code:Marital Status:Occupation:Email:Family Contact InformationFirst name:Last name:Relationship to Patient:Phone Number:Mobile Number:Emergency Contact information (If different individual from above)First name:Last Name:Relationship to Patient:Phone Number:Mobile Number:Family Doctor Name:Clinic Address:Clinic Phone:Clinic Email:Past Medical HistoryPlease list any relevant past medical history including any hospitalizations, surgeries, prior injuries, or any past medical conditions etc. Be sure to include any previous family medical conditions or diseases that may be relevant.Ongoing Health Conditions/ Allergies/Drug Reactions/ Risk Factors/Long Term TreatmentPlease list any ongoing health conditions, allergies, drug reactions, and long term treatments that may be relevant. If you are currently taking any prescription medications, please include them.Please circle any conditions you are experiencing (past and present):General SymptomsCardiovascularDental decayColitisHeadaches/migrainesHigh or low blood pressureGum troubleHemorrhoidsFeverPrevious stroke or TIAFrequent coldsHypoglycemiaChillsSweatHigh cholesterolEnlarged thyroidHiatal herniaMemory lossSwelling of anklesTonsillitisMetallic tasteDizziness/Light headinessPoor circulationSinus infectionFaintingStroke/heart attackNasal drainageStress/depressionIrregular heart beatEnlarged glandsDiscoordinationShortness of breathNervousnessPain over heartFor Women OnlyRecent weight loss/gainSkinCramps/backacheNumbness pain in arms, legsSkin conditions/rashesPrevious miscarriageGenitourinary SystemFrequent/painful urinationItchingBruise easilyIrregular cycleVaginal dischargeBlood in urine/stoolDrynessLumps in breastRespiratoryWheezingMucus in stoolKidney infection/kidney stoneBoilsVaricose veinsMenopausal symptomsChronic coughBladder infectionSensitive skinPregnantSpitting up phlegmInability to control urineHives or allergyPainful menstruationChest painExcessive flowDifficulty breathingHot flashesEars, Eyes, Nose, ThroatGastrointestinalPoor appetiteHysterectomyMuscle and JointHearing lossVision problemsGlaucomaDistress from greasy foodsStiff neckBack acheRinging in ear(s)Crossed eyesExcessive hunger/thirstSwollen jointsEye painBelching or gasPainful tailboneDeafnessNauseaPain in shoulderEaracheVomitingHerniaEar dischargeBurning in stomachSpinal curvatureNose bleedsPain over stomachFaulty postureNasal obstructionConstipation/diarrheaArthritisSore throatColon troubleFoot troubleHoarsenessLiver trouble/hepatitisHay feverGall bladderAsthmaUlcersHave you had any of the following?AppendicitisMalariaChicken poxAlcoholismOsteoporosisDiabetesVenereal infectionCold soresWhooping couchCancerEpilepsyMultiple sclerosisAnemiaHeart diseaseTuberculosisPneumoniaMeaslesGoiterEczemaMental illnessMumpsInfluenzaGoutPolioPleurisyPneumatic feverArthritisRubellaParkinson’s HIV/AIDSSignature of Patient: or Substitute Decision-Maker: Date:_______________________________Relationship to Patient: ________________________ ................
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