Medical History New Patient

LName
FName
Birthdate
misc
misc
misc
misc
misc
inputMed1
inputMed4
inputMed3
inputMed2
inputMed9
inputMed10
inputMed7
inputMed5
inputMed6
inputMed8
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
misc
misc
misc
misc
misc
misc
misc
misc
misc