Patient Medical History Form
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4PATIENT MEDICAL HISTORY FORM
PATIENT NAME: ___________________________________________________
CHIEF COMPLAINT:
What is the main reason for your visit today?
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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Please answer the following questions about your present medical problem as it applies to you.
Please check all that apply
PAST MEDICAL HISTORY:
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Cancer
Diabetes
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Lymphoma
Kidney Disease
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Leukemia
Tuberculosis
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Blood Problem
Asthma
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Rheumatologic Disease
Heart Disease
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High Blood Pressure
Arthritis
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Thyroid Problems
Lung Disease
COPD/
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High Cholesterol
Other
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PAST SURGICAL HISTORY: Please check all that apply and list date:
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Appendectomy (Appendix) ____________
Inguinal Hernia_____________________
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Cataract Removal ___________________
Laminectomy ______________________
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Breast Augmentation _________________
Prostatectomy (Prostate) ______________
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Cholecystectomy (Gall bladder) ________
Splenectomy (Spleen) ________________
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Breast Biopsy ______________________
Thyroidectomy _____________________
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Coronary Artery Bypass ______________
Tonsillectomy ______________________
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Breast Mastectomy___________________
Colon Surgery______________________
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Hysterectomy Total __________________
Other _____________________________
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Hysterectomy Partial__________________
If you have had cancer, have you ever received chemotherapy or radiation: ____Yes ____No if so, explain:
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P: CCC Forms/Front Office/New Patient Forms
Revised 6/18/2014
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