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HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.

Marital status: Required

PERSONAL HEALTH HISTORY

Childhood illness:
Immunizations and dates:

Surgeries:

Other hospitalizations

Have you ever had a blood transfusion?

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Allergies to medications

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