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Patient Occupation
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Employer Name
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How did you find us?
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Do we have permission to leave a message on your home phone?
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Do we have permission to leave a message on your cell phone?
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Do we have permission for email communication?
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Do we have permission to discuss your medical condition with any member of your household?
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If yes, whom (specify relationship)
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Review of Systems (please click the box if you have any of the following):
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AIDS or HIV
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Hepatitis
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Anemia
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high blood pressure
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Arthritis
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Irregular heart beat
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Asthma
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Kidney problems
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Back problems
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Migraine headaches
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Blood clots in legs
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Nervous breakdown
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Blood disorders
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Nose/throat problems
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Bleeding problems
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Pneumonia
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Breathing problems
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Psychiatric condition
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Cancer
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Rheumatic fever
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Chest pains
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Seizures
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Colitis
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Shortness of breath
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Diabetes
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Skin cancer
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Ear/Eye Problems
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Stomach problems
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Epilepsy
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Stroke
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Heart problems
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Thyroid problems
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Heart murmurs
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Tuberculosis
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Heart palpitations
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Transfusion
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Medical, Family, and/or Social History
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Do you have any medical conditions? (if none, please state none):
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List any hospitalizations and/or previous surgeries (including cosmetic), with dates (if none, please state none):
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Are you taking any regular medications? (if none, please state none):
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Have you taken Accutane or Isotretinoin in the last 12 months?
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Do you have allergies to medications? (if none, please state none):
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Do you currently smoke?
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Have you ever smoked?
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Do you drink alcohol
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If yes, how much?
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Have you ever had breast cancer?
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Do you have any relatives who have had breast cancer?
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Have you ever had a mammogram?
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If yes, when was it done, and what was the result?
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Do you have a problem with excessive scarring or keloid formation?
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Have you ever had pyschiatric problems, been under the care of a pyschiatrist, pyschologist, or mental health counselor?
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What is your current weight? (lb)
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What is your current height? (feet)
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Have you had a COVID-19 vaccine?
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