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Does anyone in your family have any of the following ALLERGY TO FOODS OR MEDICINES HEART ISSUES HIGH BLOOD PRESSURE HIGH CHOLESTEROL ASTHMA/LUNG ISSUES CANCER DIABETES OVERWEIGHT THYROID ISSUES KIDNEY OR BLADDER ISSUES MIGRAINES SEIZURES VISION OR DEPRESSION OR ANXIETY ANYTHING ELSE YES NO Any recent changes in home or family situation describe Anything else in family or social history that would help us care for this patient. DATE COMPLETED FAMILY HISTORY PATIENT S NAME SIBLING S NAME S DATE...
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