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CURRENT HEALTH CONCERNS
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Current Concerns (Select all that apply)
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If concern(s) not listed, please specify:
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Briefly describe your concerns:
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PAST HEALTH CONCERNS
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General (Select all that apply)
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If not listed, please specify:
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Skin (Select all that apply)
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If not listed, please specify:
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Head (Select all that apply)
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If not listed, please specify:
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Neck (Select all that apply)
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If not listed, please specify:
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Nose/Throat/Mouth/Tongue (Select all that apply)
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If not listed, please specify:
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Ears (Select all that apply)
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If not listed, please specify:
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Eyes (Select all that apply)
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If not listed, please specify:
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Cardiovascular (Select all that apply)
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If not listed, please specify:
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Respiratory (Select all that apply)
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If not listed, please specify:
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Gastrointestinal (Select all that apply)
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If not listed, please specify:
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Urogenital (Select all that apply)
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If not listed, please specify:
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Male Reproductive (Select all that apply)
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If not listed, please specify:
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Female Reproductive (Select all that apply)
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If not listed, please specify:
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Endocrine (Select all that apply)
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If not listed, please specify:
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Neurological (Select all that apply)
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If not listed, please specify:
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Psychological (Select all that apply)
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If not listed, please specify:
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Musculoskeletal (Select all that apply)
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If not listed, please specify:
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I wish to decline the following treatments:
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