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NEW PATIENT MEDICAL HISTORY

YOUR MEDICAL HISTORY IS VERY IMPORTANT; THEREFORE, PLEASE FILL OUT ALL ITEMS COMPLETELY. IF THE QUESTIONS DO NOT APPLY, THEN GO ONTO THE NEXT. ALL INFORMATION IS HELD IN STRICT CONFIDENCE.

List the approximate DATE of last test and whether NORMAL or ABNORMAL

Please list your family history below to include the # alive, # deceased, age when deceased, and any major illnesses.

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