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Personal Health History

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Patient First Name

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Patient Last Name

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Email

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Account #:

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Past Medical History

Past Medical History

High Blood Pressure

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Diabetes

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Heart Attack

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Thyroid Disease

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Anemia

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Heart Disease

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High Cholesterol

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Asthma

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Depression

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Hospitalization

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Why?

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Other Illness List

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Number of Pregnancies

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Number of Children

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Date of Last Menses

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Past Surgery

Past Surgery

Appendix

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Tonsils

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C-Section

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Gallbladder

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Hysterectomy

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Other Surgeries

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Current Medications

Current Medications

Medication Name

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Dose

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When Taken

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Refills Needed

Yes

No

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Medication Name

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Dose

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When Taken

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Refills Needed

Yes

No

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Medication Name

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Dose

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When Taken

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Refills Needed

Yes

No

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Medication Name

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Dose

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When Taken

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Refills Needed

Yes

No

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Allergies? (If yes, please explain)

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Family History

Family History

Heart Disease

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High Blood Pressure

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Diabetes

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Stroke

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Cancer

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Depression

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Work History

Work History

Current Occupation

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History of exposure to chemicals, fumes of asbestos

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Any Job Related Injury?

Yes

No

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Are you disabled?

Yes

No

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Why?

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Social History

Social History

Smoke

Yes

No

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How much? Packs per day

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Started Years Ago

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Quit

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Alcohol

Yes

No

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How Many Drinks? Per day or week (circle one)

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IllegalDrugs

Yes

No

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History of sexually Transmitted Diseases

Yes

No

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Do you think you have any risk of AIDS?

Yes

No

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106 Lansford Court, Suite 100,
Myrtle Beach, SC 29588

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