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Select if you are a new patient
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Select if you were a patient in Dr. Marrs' prior practice
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Reason(s) for today's visit:
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Select if you were referred to our practice
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If referred to us, name of doctor who referred you
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Medical History (Include anything for which you take medication)
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Previous Surgeries
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Please make a selection in each box below
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Review of Systems
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General Health (Select all that apply)
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Eyes
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Ears
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Nose/Sinus
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Mouth/Throat/Neck
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OTHER Head & Neck or ENT problem
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Cardiovascular
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Respiratory
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Gastrointestinal
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Genital & Urinary Tract
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Skin (inludes breast)
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Muscles and Bones
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Neurologic
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Psychiatric
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Endocrine
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Blood
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Immune System
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OTHER symptom not listed above
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Appointment Type
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