Medical History New Patient

We are pleased to welcome you to our office. Please take a few minutes to fill out as completely as you can. If you have any questions we will be glad to help you.
LName
FName
Birthdate
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inputMed7
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allergy:Anesthetic
allergy:Aspirin
allergy:Codeine
allergy:Ibuprofen
allergy:Iodine
allergy:Latex
allergy:Penicillin
allergy:Sulfa
problem:Asthma
problem:Bleeding Problems
problem:Cancer
problem:Diabetes
problem:Heart Murmur
problem:Heart Trouble
problem:High Blood Pressure
problem:Joint Replacement
problem:Kidney Disease
problem:Liver Disease
problem:Pregnancy
problem:Psychiatric Treatment
problem:Sinus Trouble
problem:Stroke
problem:Ulcers
problem:Rheumatic Fever
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