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Click ‘Get Form’ to open it in the 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 whether you have had any of the listed conditions by checking 'Yes' or 'No'.
Proceed to the 'PAST SURGICAL HISTORY' section and check off any surgeries you have undergone.
List any regular medications you are taking in the 'MEDICATIONS' section, including drug names, strengths, and frequency.
Complete the 'ALLERGIES TO MEDICATIONS / OTHER' section by noting any allergies you may have.
Fill out the 'SOCIAL HISTORY' section with details about your lifestyle habits such as tobacco and alcohol use.
In the 'FAMILY HISTORY' section, provide information about your family’s health history as requested.
Finally, review all entries for accuracy before signing and dating at the bottom of the form.

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