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Patients Name:___________________________________
Todays Date: ____________________
What was the approximate date of your last yearly exam in
this office ___________________
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of that last exam have you: |
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Been hospitalized? Please describe reason
and date of hospitalization.
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Had Surgery? List reason for surgery and
date
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Given Birth? Vaginal or C/section? Any
complications?
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Had any accidents or ER visits? Explain
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Has your Family History Changed at all?
Any new diagnoses in your Family?
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| When was your
last mammogram? |
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Approximate Date:
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Where was it done? (circle one)
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Fryecare // Catawba Imaging //
Caldwell/Lenoir // Blue Ridge Radiology // Other
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| List Current
Medications: |
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| Current
Allergies to medications or latex? PLEASE
LIST |
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