MEDICAL HISTORY
Name __________________________________________________ Date of Birth ____________
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Now |
Past |
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Now |
Past |
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Now |
Past |
General |
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Urinary |
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Endocrine |
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Weight loss |
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Frequent urination |
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Thyroid Problem |
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Fever/Chills |
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Burning |
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Diabetes |
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Fatigue |
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Blood in urine |
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Headaches |
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Urinary infection |
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Blood |
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Kidney Stones |
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Blood clots |
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ENT |
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Incontinence |
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Bleeding problems |
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Hearing loss |
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Sexual difficulty |
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Leukemia |
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Ringing ears |
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Male testicle pain |
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Anemia |
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Blurred vision |
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Female painful menses |
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Phlebitis |
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Earaches |
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Female vag. discharge |
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Enlarged spleen |
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Nose bleeds |
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Hepatitis |
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Bleeding gums |
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Musculoskeletal |
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HIV |
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Sore throat |
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Joint pain |
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AIDS |
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Swollen glands |
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Stiffness |
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Weakness |
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Heart |
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Back pain |
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Heart failure |
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Cold feet or hands |
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Heart Attack |
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Poor circulation |
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Angina |
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Leg swelling |
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Skin/Breast |
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Palpitations |
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Rash/itching |
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Rheumatic fever |
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Change in color |
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High Blood
Pressure |
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Varicose veins |
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Breast pain |
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Lungs |
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Breast lump |
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Pneumonia |
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Breast discharge |
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Emphysema |
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Breast cancer |
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Bronchitis |
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Cancer |
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Neuro |
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Shortness of breath |
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Dizzy spells |