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Patient Medical Information Sheet

Patient Information sheet to be filled out at initial Doctor's Office visit.

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Medical Information Template

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Patient Medical Information

Name: ________________________________________ DOB: ____/____/______

Occupation: ___________________________________ Education: ________________

Marital Status: Single / Married / Divorced / Widowed

Tobacco Product Use: None / Current Use / Past Use Type of Product: _______

How much per day? _____________________________ For how long? _________

Daily Caffeine consumption? Yes / No How much per day? ______

Alcohol Use? Yes / No How much per day? __________________

Do you currently exercise? Yes / No How often? ________ What type? ______

Females: Number of pregnancies _____ Number of Live Births _____Type of delivery ________

Medication Allergies:


Other Allergies:




Current Medical Problems:


Past Medical Problems:


Family Medical History:


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