Chart # Doctor Date history was received: Present Cause of
Date history was received: Date of Birth: FAMILY HISTORY PAST MEDICAL HISTORY FEMALE HISTORY: Age of onset of periods Are your periods regular? Number of pregnancies: Number of miscarriages: Age of “Change of Life”: Do you do self breast exam? Have you Had Any Of The Following Illnesses Or Disorders? Heart Problems High Blood Pressure Sugar Diabetes Overweight Stroke … ................
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