Past Medical History Information

:
Please list your past surgeries/hospitalizations with dates of each:
If you selected 'Yes' to Respiratory Illness, please specify the type here. (Asthma, COPD, etc.)
If you selected 'Yes' for Cancer, please specify the type of cancer.
Please least any other past or current medical conditions not listed above.
Is there a family history of the illness/condition we are seeing you for today? If so, please specify relationship of family member.
Please list your drug allergies:
Please specify all current medications you are currently taking. Leave blank if none.

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