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Health History - Adult Female

Smoking, alcohol, drugs, abuse

If pre-menopausal:


If post-menopausal:

MEDICAL/SURGICAL HISTORY


FAMILY HISTORY
Please check if there is a family history of any medical problems below (mother, father, siblings, grandparents, aunts, uncles, cousins) for both maternal (mother's) or paternal (father's) side.

Please type family member next to problem, i.e. mother, father, etc., and use (M) for maternal and (P) for paternal.

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