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    We hope you will answer the questions on this medical history form as thoughtfully as possible. Many of the questions that follow may not seem directly related to your main complaint or reason for seeking care. However, the answers to these questions, as well as the information you provide in the office, will determine the individualized approach taken to begin your treatment. Please consider this an opportunity to write anything you think may be pertinent to your health that you may not have spoken with any other provider in the past. ALL THE INFORMATION IN THIS QUESTIONNAIRE IS CONFIDENTIAL BY LAW.

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  • Context of Care

  • Your Medical History - Please check all that apply

  • General States of Health - Please check all that apply

  • Head, Ears, Eyes, Nose, and Throat - Please check all that apply

  • Skin, Hair & Nails - Please check all that apply

  • Respiratory & Cardiac- Please check all that apply

  • Gastrointestinal- Please check all that apply

  • Genitourinary- Please check all that apply

  • Menstrual/Menopausal- Please check all that apply

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  • Please check all that apply:

  • Endocrine- Please check all that apply

  • Musculoskeletal and Neurological - Please check all that apply

  • Psychosocial - Please check all that apply

  • 3 Day Diet History

  • PLEASE DO NOT SKIP THIS SECTION.

    This does not need to be an exact 3 days of your life. Most people eat approxiametly the same things for breakfast, lunch, and dinner. Please list food AND drink items you consume on a regular basis. It is not necessary to write amounts of each item. (eg. Simply write "peas"; Not necessary to write 1/2 cup of peas.)

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  • Personality Questions

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  • I hereby certify that the above information is true and accurate to the best of my knowledge.

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  • Should be Empty: