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Health History - Adult Male



LIFESTYLE/RISK ASSESSMENT:
Smoking, alcohol, drugs, abuse


exercise and diet


SEXUAL HISTORY


PREVENTATIVE CARE

Check if you have had any of the following:



IMMUNIZATIONS


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) and indicate if it is on the maternal (M) or paternal (P) side.

 


REVIEW OF SYSTEMS