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Anxiety

Name:. Birthdate:. Past Medical History. Please select any of the following conditions that you currently have:. Anxiety. Hearing Loss. Arthritis. Hepatitis. Asthma. Hypertension. Atrial Fibrillation. HIV/AIDS. Bone Marrow Transplantation. Hypercholesterolemia. BPH. Hypothyroidism.

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Anxiety

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  1. Name: Birthdate: Past Medical History Please select any of the following conditions that you currently have: Anxiety Hearing Loss Arthritis Hepatitis Asthma Hypertension Atrial Fibrillation HIV/AIDS Bone Marrow Transplantation Hypercholesterolemia BPH Hypothyroidism Breast Cancer Leukemia Colon Cancer Lung Cancer Coronary Artery Disease Lymphoma Depression Prostrate Cancer Diabetes Radiation Treatment End Stage Renal Disease Seizures Other (Enter Below) Stroke 2. Other: 3. Other: 4. Other: Physician List: Please list the name and location of your physicians: 1. Primary care physician:

  2. Past Surgeries Please select any of the following surgeries that you have had: Appedix (Appendectomy) Joint replacement: knee both Bladder (Cystectomy) Joint replacement: hip right Breast: mastectomy (right breast) Joint replacement: hip left Breast: mastectomy (left breast) Joint replacement: hip both Breast: mastectomy (both breasts) Kidney: kidney biopsy Breast: lumpectomy (right breast) Kidney: nephrectomy Breast: lumpectomy (left breast) Kidney: kidney stone removal Breast: lumpectomy (both breasts) Kidney: kidney transplant Breast: breast biopsy Ovaries (oophorectomy): endometriosis Breast: breast reduction Ovaries (oophorectomy): ovarian cyst Breast: breast implants Ovaries (oophorectomy): ovarian cancer Colon (colectomy): colon cancer resection Prostate (prostatectomy): prostate cancer Colon (colectomy): diverticulitis Prostate: prostate biopsy Colon (colectomy): inflam. bowel disease Prostate (prostatectomy): TURP Gall bladder (cholecystectomy) Skin: skin biopsy Heart: coronary bypass surgery Skin: basal cell carcinoma Heart: coronary stent placement Skin: squamous cell carcinoma Heart: mechanical valve Skin: melanoma Heart: biological valve Spleen (splenectomy) Heart: heart transplant Testicles (orchiectomy) Joint replacement: knee right Uterus (hysterectomy): fibroids Joint replacement: knee left Uterus (hysterectomy): uterine cancer Other surgeries (enter below)

  3. Skin Disease History Have you had any of the following conditions? Acne Flaking or itchy scalp Actinic Keratoes Hay fever/allergies Asthma Melanoma Basal cell skin cancer Poison ivy Blistering sunburns Precancerous moles Dry skin Psoriasis Eczema Squamous cell skin cancer Other skin conditions: Lung Cancer Do you wear sunscreen? If yes what SPF? ______ No Yes Do you tan in a tanning salon? No Yes Do you have a family history of melanoma? No Yes If yes which relative ? ________________

  4. 9. 8. 7. 6. 5. 10. 3. 2. 1. 4. Medications: Allergies: Please list any medication allergies you have and what your reaction was. Drug Reaction 3. 1. 2. 4.

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