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Medical Information
* Indicates required question
Name:
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Please check any of the following that apply to you and/or members of your family.
Thyroid disease
Kidney disease
Asthma
Infectious diseases
Seizures
Cardiovascular disease
TMJ disorder (clenching jaw)
Diabetes
Cancer
Gastrointestinal disease
Prostate problems
Tremors
Ulcers
Migraine headaches
Neurological disease
Other:
Have you had a physical exam in the last year?
*
Yes
No
Do you have any current concerns about you physical health?
*
Yes
No
If yes, please explain:
Your answer
Are you currently under the care of a general medical practitioner?
*
Yes
No
If yes, please indicate the physician's full name & telephone number:
Your answer
Are you currently under the care of a medical specialist (e.g., psychiatrist or cardiologist)?
*
Yes
No
If yes, please indicate the physician's full name & telephone number:
Your answer
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