New Patient Form
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Patient Information
Patient Information
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Present Symptoms/Complaints
Present Symptoms/Complaints
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Lifestyle
Lifestyle
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How many packs a day?
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Past/Present Medical History
Past/Present Medical History
Past/Present Medical History: PLEASE CHECK ALL THAT MAY APPLY TO YOU AND WRITE ANY OTHERS
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Past Surgical History/Hospitalization
Past Surgical History/Hospitalization
Past Surgical History/ Hospitalizations: PLEASE CHECK ALL SURGERIES THAT MAY APPLY TO YOU AND WRITE ANY OTHERS
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Family History Father
Family History Father
Father
Family History Mother
Family History Mother
Mother
Family History Brother
Family History Brother
Brother
Family History Sister
Family History Sister
Sister
Family History Son
Family History Son
Son
Family History Daughter
Family History Daughter
Daughter
Medication/Allergies
Medication/Allergies
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No Known Allergies (select the check box below)
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