Health History - Adult Male

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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.



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