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3. MEDICAL QUESTIONNAIRE ALL MUST COMPLETE

PATIENT MEDICAL QUESTIONNAIRE

PLEASE INCLUDE ANY MIDDLE NAME OR INITIAL
PLEASE ENTER AGE IN YEARS
FEET, INCHES OR CM
POUNDS OR KILOGRAMS
IF DISABLED, PLEASE LIST PRIOR OCCUPATION
PLEASE ALSO INCLUDE TOWN, STATE

GENERAL PAST MEDICAL HISTORY

MEDICATIONS

IF SO LIST BELOW
Narcotics only. Enter "n/a" if not applicable.
Enter "n/a" or "none" if not applicable
Enter "n/a" or "none" if not applicable

ALLERGIES

or enter "none"

SURGICAL HISTORY

Please select any surgeries you have had and list dates.

List any other surgeries with dates:

FAMILY HISTORY

SMOKING HISTORY

Enter "0" or "n/a" if not applicable.
"n/a" if not applicable.

DRUG RELATED QUESTIONS

IF YOU FEEL THAT THE DOCTOR SHOULD KNOW ANYTHING ELSE OF IMPORTANCE THAT HAS NOT BEEN PREVIOUSLY MENTIONED

WARNING: YOU MUST CLICK "SUBMIT FORM" AND SEE A MESSAGE IN GREEN STATING "SUCCESSFULLY SUBMITTED" BEFORE GOING TO THE NEXT FORM OR THE ENTIRE FORM WILL BE LOST

* Required field