NAME


Medical History

 
Patient Information
Marital Status
 
 
 
 
Past Medical History





























 


Menstrual History
Are you menopausal

Hormone Replacement Therapy

Birth Control Method








Surgical History



















Pregnancy History



Sex
Delivery

Sex
Delivery

Sex
Delivery

Sex
Delivery

Sex
Delivery

Sex
Delivery
Social History







Family Medical History








Allergies
Any medication allergies?

Medication List
Prescription and/or non-prescription-including vitamins you are currently taking






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