Medical History
Prepared by: [YOUR NAME]
Personal Information
Full Name: | Adelia Harber |
Date of Birth: | 01/12/2050 |
Gender: | |
Contact Number: | 222 555 7777 |
Email Address: | adelia@you.mail |
Address: | Mesa, AZ 85201 |
Medical History
Please provide detailed information regarding your medical history. Include conditions, treatments, and any ongoing medical care you are currently receiving.
Do you have any chronic illnesses? | |
If yes, please specify: | |
Are you currently taking any medication? | |
If yes, please list the medications: | |
Allergies
Please list any known allergies and the reactions they cause.
Do you have any allergies? | |
If yes, please specify: | |
Family Medical History
Provide any relevant medical history information for your immediate family members such as parents, siblings, and grandparents.
Family history of medical conditions: | Grandfather has a history of hypertension. |
Please ensure all information provided is accurate to the best of your knowledge.
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