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Histórico médico
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Histórico médico
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Date
*
Name
*
First
Last
Treatment Type:
*
Age:
*
Height:
*
Weight:
List of medications you are currently using (ncluding over-the-counter medications):
List of surgeries you have performed before (including plastic surgeries):
Date
Surgical Intervention:
Use herbal supplements or vitamins (especially Gingko, ginger, garlic, St. John’s Wort, C, E, fish oil)?:
Medicines that cause allergies:
Are you a smoker?
YES
NO
If yes; For how long?
Are you an alcohol user?
YES
NO
If yes; what quantity?:
Do you have any of the following symptoms?
Chest pain:
YES
NO
Breast diseases:
YES
NO
Seizure:
YES
NO
Heart problems:
YES
NO
Thyroid problems:
YES
NO
Tooth problems:
YES
NO
High blood pressure:
YES
NO
Hepatitis C:
YES
NO
Emotional problems:
YES
NO
Diabetes:
YES
NO
Kidney problems:
YES
NO
HIV:
YES
NO
Cancer:
YES
NO
Asma:
YES
NO
Eye problems:
YES
NO
Problems with bleeding:
YES
NO
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