Contact

mail@gemini-theme.com
+ 001 0231 123 32

Follow

Info

All demo content is for sample purposes only, intended to represent a live site. Please use the RocketLauncher to install an equivalent of the demo, all images will be replaced with sample images.

Health History - Adult Male

Please fill in all relevant information.

* NOTE *  You must expand each section to fill out the information

 


Smoking, alcohol, drugs, abuse

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:  Check if you CURRENTLY have problems with any of the following:

  Refresh Captcha