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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

If "None" is indicated, patient is denying having a history of urinary incontinence, pain with sex, Hepatitis B, Hepatitis C, chlamydia, gonorrhea, yeast, genital herpes, genital warts, infertility, syphilis, and HIV/AIDS

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


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