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  • Patient Medical History: Option 2

    Uploaded by

    natasha torres
    5 views1 page
    This patient medical history form collects information about drug allergies, past illnesses, operations, current medications, exercise habits, diet, alcohol and caffeine consumption, smoking status, and other comments regarding the patient's medical history. It requests the patient's name, birthdate, height, weight, gender, and reason for seeing the doctor.

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    Original Title

    201894491948066

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    This patient medical history form collects information about drug allergies, past illnesses, operations, current medications, exercise habits, diet, alcohol and caffeine consumption, smoking status, and other comments regarding the patient's medical history. It requests the patient's name, birthdate, height, weight, gender, and reason for seeing the doctor.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    5 views1 page

    Patient Medical History: Option 2

    Uploaded by

    natasha torres
    This patient medical history form collects information about drug allergies, past illnesses, operations, current medications, exercise habits, diet, alcohol and caffeine consumption, smoking status, and other comments regarding the patient's medical history. It requests the patient's name, birthdate, height, weight, gender, and reason for seeing the doctor.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Date

    8/7/2020

    PATIENT MEDICAL HISTORY

    Please list any drug allergies

    PATIENT INFORMATION
    Have you ever had (Please check all that apply)

    Other illnesses

    Birth Date
    Please list any Operations

    Height (cm's)
    Please list your Current Medications

    Weight (kg's)
    HEALTHY & UNHEALTHY HABITS

    Gender
    Exercise

    Reason for seeing the


    Eating following a diet
    doctor

    Alcohol Consumption

    Caffeine Consumption

    Do you smoke?

    Include other comments regarding your Medical History


    Option 2

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