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PATIENT MEDICAL HISTORY Patient Name Age DOB Please list all daily medications (and dosages): Med Med Med Dose Dose Dose Med Med Med Dose Dose Dose Date of Visit For Office Use: Room# HT: WT: BP:
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Open the patient med hx 33010doc form
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Start by filling out the patient's personal information, such as their name, date of birth, and contact details
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If the patient is currently taking any medications, list them along with the dosage and frequency
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Include any known allergies or adverse reactions to medications
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