Name ________________________________________________ DOB________________
Past Medical History
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ICD9 Code |
Chronic Problems |
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Hospitalizations/Serious Injuries |
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Surgeries |
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Allergies – Please list all drug, food, and/or environmental allergies.
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Medications – Please include any medication, vitamin or herb that you have taken over the last 6 months.
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| Social History | ///////////////////////////////////////////////////////// | Family History | Problem | Age | |
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Marital Status |
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Mother |
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Children |
Boys Girls |
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Father |
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Work |
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Maternal Grandmother |
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Religion |
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Maternal Grandfather |
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Education level |
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Paternal Grandmother |
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Hobbies |
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Paternal Grandfather |
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Drug use |
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Tobacco (ppd) |
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Alcohol use |
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Please list anything else that may be important about your health condition.
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COLUMBIA COUNTY VIM CLINIC 310 EAST THIRD ST. P.O. BOX N MIFFLINVILLE, PA 18631
570-752-1780 570-752-1786 (FAX)