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This healthcare form shows how to:
  • capture basic patient information
  • ask multiple questions with required answers
  • aks for the user's signature
Lease
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Date of Birth Missing or incorrect value
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Constitutional
Missing or incorrect valuefever, heat stroke, weight loss, weight gain, unusually tired, etc.
Ear/Nose/Throat
Missing or incorrect valuehard of hearing, stuffy nose, earache, cough, dry mouth, etc.
Heart (Cardiovascular)
Missing or incorrect valuehigh blood pressure, racing pulse, chest pain, unable to exercise, etc.
Lungs (Respiratory)
Missing or incorrect valuecongestion, wheezing, shortness of breath, productive or bloody cough, asthma, etc.
Digestion (Gastrointestinal)
Missing or incorrect valuestomach upset, diarrhea, constipation, hernia, ulcers, pain/cramps, acid reflux, etc.
Muscles and bones (Musculoskeletal)
Missing or incorrect valuemuscle pain/cramps, joint pain swelling, stiffness, etc.
Urological
Missing or incorrect valuepainful or frequent urination, burning, impotence, incontinence, infections, etc.
Gynecological
Missing or incorrect valuepregnancies, menstrual problems, ovarian and uterine conditions, etc.
Breast
Missing or incorrect valuecysts, fibroids, pain, numbness, lumps, etc.
Neurological
Missing or incorrect valuenumbness, weakness, headaches, paralysis, seizures, tremors, tingling, etc.
Psychiatric
Missing or incorrect valuedepression, anxiety, mood swings, insomnia, hallucinations, disorientation, etc.
Blood/Lymphatic
Missing or incorrect valuehigh cholesterol, anemia, blood disorders, leukemia, prolonged bleeding, etc.
Skin
Missing or incorrect valueitching, rash, infection, ulcer, tumors or growths, warts, excessive dryness, etc.
Cancer
Missing or incorrect valuefever, heat stroke, weight loss, weight gain, unusually tired, etc.
Allergic/Immunologic
Missing or incorrect valuerecurrent infections, hay fever, food allergy, drug sensitivity, hives, redness, itching, etc.
Hormones (Endocrine)
Missing or incorrect valuediabetes, thyroid problems, fatigue, hair loss, hot/cold intolerance, etc.
Major illnesses/hospitalizations
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Surgeries
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If diabetic: Year of diagnosis

Systemic Disease

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Have you been exposed to venereal disease/sexually transmitted infection?
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Are you pregnant
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Occupational exposure
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Recent travel
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Tobacco use
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Alcohol use
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Recreational drug use
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Medications: List ALL medications you are CURRENTLY taking. (Include all herbals, vitamins and supplements)

Name
Dose
Frequency
Other information

Allergies: Please list ALL allergies

Allergy
Severity
Reaction
Treatment information

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Signature
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Date Missing or incorrect value
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b29465c5b7970a070a8b646723faae99cc1f3fbd
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