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ADULT MEDICAL HISTORY FORM Name - Texas Family Physicians 2025

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The document is an Adult Medical History Form used by Texas Family Physicians in Austin, Texas. It collects comprehensive patient information including past medical and surgical history, current medications, allergies, social history, family medical history, and insurance details. Additionally, it includes sections for authorization of medical record disclosure, office policies, a notice of privacy practices regarding the handling of medical information, and acknowledgment of receipt of these practices.

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Click ‘Get Form’ to open the ADULT MEDICAL HISTORY FORM in our editor.
Begin by entering your personal information at the top of the form, including your name, sex, date of birth, and age.
In the 'PAST MEDICAL HISTORY' section, indicate any relevant medical conditions by checking 'Yes' or 'No' for each item listed.
Proceed to the 'PAST SURGICAL HISTORY' section and similarly mark any surgeries you have undergone.
Fill out the 'MEDICATIONS' section by listing all current medications, their strengths, and how often you take them.
Complete the 'ALLERGIES TO MEDICATIONS / OTHER' section by noting any allergies you may have.
Continue through sections on social history and family history, providing detailed responses as necessary.
Finally, review all entered information for accuracy before signing and dating the form at the bottom.

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