Name of Patient/Patient Record/Medical History

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The Medical History page is under construction. You won't see these pages any more later on anyway. If you fill one in for fun, I will receive it.

Patient #

Last, First & MI
,

SSN

Medical History

Pneumothorax
COPD
Asthma
Emphysema
Other
Date
Date
Date
Date
Date

Smoking Yes No Packs per day Years

Alcohol Yes No Amount per day oz liquor

Heart Attack
Congestive Heart Failure
Hypertension
Hypotension
Pacemaker
Other
Date
Date
Date
Date
Date
Date

The Treatment page is under construction. You won't see these pages any more later on anyway. If you fill one in for fun, I will receive it.