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Risk Factors
Are you ever had a high Tryglyceride or Cholesterol level?
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Do you have any type of Drug habit?
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Are you exercise regularly?
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Are you Overweight?
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Do you currently or have you ever smoked cigarettes?
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Polio
Yes
No
If so, how many packs per day?
How many years have you smoked?
Do you drink Alcohol?
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Please estimate the amount of coffee, tea and caffeinated soft drinks you consune each day.
If so, estimate the amount you drink in one week.
Covid-19
Have you had COVID-19?
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Have you been in close contact (within 6 feet) with someone who is diagnosed with COVID-19?
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Are you clear of COVID-19 now?
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No
Since which date?
Have you been tested for COVID-19?
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Test Date
Test Result
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Past Surgeries
Have you had an opereation on any of the following?
Appendix
Tumor of any Kind
Hernia
Gallbladder
Varicose Veins
Hemorrhoids
Kidney
Thyroid
Chest
Tonsils
Breast
Illnesses
Check any of the following medications ypu are presently taking or have taken in the past year?
Anemia
Blood Transfusions
Nervous Breakdown
Bleeding Disorder
Hernia
Varicose Veins
Jaundice
Hemorrhoids
Ulcer
Diabetes
Colitis
Gallbladder Disease
Cancer
Arthritis
Tuberculosis
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Bone Disease
Hepatitis
Hepatitis
Blood Clots or Phlebitis
Back Trouble
Pneumonia
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Asthma or Hay Fever
Skin Disease
Heart Murmur
Convulsion
Allergy or Drug Reactions
High Blood Pressure
Kidney Stone
Medication
Have you ever had any of the following?
Cortisone or Steroids
Hormones
Blood Pressure Pills
Sleeping Pills
Typhoid
Asthma Medicine
Heart Medicine
Arthritis Medicine
Antibiotics
Tranquilizer or Nerve Pills
Pain Medicine
Diet Pills
Diuretic
Hospitalization
If you have been hospitalized for any non-surgical illness, please list below (excluding childbirth).
Hospital
Year
Diagnosis
Kidney & Bladder
Difficult or Painful Urination
Blood in Urine
Can't Hold Urine
Very Frequent Urination
Kidney Disease
Kidney Stones
Protein in Urine
frequent infections
Sugar In Urine
Get up more than once at night to urinate
Muscles, Bones & Joints
Deformities
Muscle Weakness
Pain in Joints
Chronic Pain in Back
Swelling in Joints
Gout
Nervous System
Frequent or Severe Headaches
Head Injury
Convulsion / Eplispy
Numbness or Tingling
Feel Sad or Depressed
Dificulty Sleeping
Suicidal thoughts
Severe Anxiety
Desired Psychistric Help
Weakness
Immunization
Last Injections Tetanus
Last injections Tuberculosis
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Menstrual Period Began Date
No Of Pregnancies
No Of Normal Deliveries
No Of Premature Deliveries
No Of Miscarriages
No Of Abortions
No Of Living Children
Last Pap Snear Date
Birth Control Method
Do You Know How To Examine?
Your Breasts
Abnormal Pap Snear
Unusual Vaginal Discharge
Irregular Periods
Abnormal Bleeding
Pain on Intercourse
Pelvic Pain
Problems With Sex
Breast Lumps
Nipple Discharge
Veneral Disease
Genitals
Sores On Penis
Discharge From Penis
Prostate Gland Trouble
Difficulty Voiding
Impotence
Veneral Disease
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$ 65.00
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