NEW PATIENT HEALTH HISTORY FORMPatient Name:Birth date:JJJ_Date:JJ_JReferring Physician:Address:Pharmacy Name:Phone Number:Reason for today’s visit:Please describe this problem:PRIOR SURGERIESCURRENT/ PRIOR ILLNESSES/ INJURIESPlease list ALL medications (prescription and non- prescription) that you take. (Include herbal remedies, vitamins, over-the-counter, street drugs, prescriptions etc.)MEDICATIONDOSAGEMEDICATIONDOSAGEDo you take any blood thinning products such as Vitamin E, Plavix, Coumadin, or Aspirin? NOYESDo you have any food, environmental, or drug allergies? | NOYES(Please explain belowALLERGYTYPEREACTIONDo you smoke? NO and Never haveYES (Please explain below]TYPE OF SMOKING figaroits, pipe marijuana, dem, etc.]HOW MUCHHOW LONGDo you drink alcohol? [ NO and Never have @ Socially Only [ Daily ] Beer/ Wine | Hard LiquorOccupation:Hand Dominance: | RIGHT | LEFTPlease describe any family health issue below:FAMILY HISTORYGOOD/ NONEUNKNOWNILLNESSES/ REASON FOR DEATHMOTHERFATHERSIBLING[‘SOTHER HEREDITARY ILLNESSPatient Signature:Date:Physician Signature:Date Reviewed:_
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