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