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HEALTH HISTORY FORM

|NAME | |DOB | |

|Reason for visit: |Today's date |

Medication allergies

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Medications

|NAME |DOSE |FREQUENCY |

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|Social History |Smoking y/n |Alcohol y/n |Illegal drugs y/n |

FAMILY HISTORY

|Blood clots | |Colon cancer/polyps | |Crohn's disease | |

|Heart disease | |Stroke | |Celiac disease | |

|Diabetes | |High blood pressure | |Ulcerative colitis | |

|cancer | |Liver disease | |Other: | |

SURGICAL HISTORY (name and date)

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MEDICAL HISTORY

|emphysema | |Blood disorder | |Hepatitis | |

|Liver disease | |Stroke/ TIA | |Heart attack | |

|Heart failure | |Atrial fibrillation | |Colon polyp | |

|Intestinal bleed | |Ulcer | |High blood pressure | |

|Diabetes | |Kidney failure | |High cholesterol | |

|Others-list | | | | | |

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