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[HEALTH] Patient Medical History & Questionnaire

[HEALTH] Patient Medical History & Questionnaire

New patient intake - please complete the following.

[ENTER ORGANIZATION NAME, ADDRESS]
Phone: (123) 456-6789
Email: YourName@YourEmail.com
Website: YourWebsite.com
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    Pick a date.
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  • for CHILD patients (if applicable)

    If the patient is a child, please complete the following
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  • Medical History

    Please answer each question as accurately as possible
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  • Women:
      Yes No
    Are you pregnant?
    Nursing?
    Taking birth control pills?
  • Redo
  • / /
    Pick a date.