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DOROTHY COHEN SERNA MD PA KELLY M. ENGLUND MD HEALTH HISTORY FORM Confidential Patient Name Today s Date Age Birthdate Date of last physical exam Height Weight What is your reason for visit Symptoms Check symptoms you currently have or have had in the past year GENERAL p Chills Depression Dizziness Fainting Fever Sweats Fortgetfulness Numbness Difficulty sleeping Weight loss Weight gain Taken diet drugs Excessive thirst CARDIOVASCULAR Chest pain High blood pressure Low blood pressure...

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