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Health History - Adult Male


Smoking, alcohol, drugs, abuse


exercise and diet

Check if you have had any of the following:


Please indicate 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.


IMMUNIZATIONS


MEDICAL/SURGICAL HISTORY


REVIEW OF SYSTEMS