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Why are you seeing the doctor today?

 

Patient Health History – Please check all that apply

Brain and Neurological

Heart/ Cardiovascular


Hormone / Endocrine

Blood / Immunity



Women

Lungs / Pulmonary


Stomach / Gastrointestianal



Kidney / Urinary Tract

Dialysis
Transplant

Bones / Musculoskeletal



Social Habits


Mental / Psychological


Have You Ever or Are You Now Taking Bisphosphonate Medication


List Drug and Food Allergies

List All Current Medications

List All Past Surgeries With Dates


Certification

I understand the importance of a truthful health history to assist the doctor in providing the best care possible. I certify that the information I have completed is true and correct to the best of my knowledge. I agree that my questions, if any, regarding the inquires set forth above have been answered to my satisfaction. I will not hold Dr. Riley J. Hicks, or any other member of his staff responsible for any errors or omissions that I may have made in the completion of this form.


 

 
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