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Personal Medical History Form Please Print PATIENTS LEGAL NAME:TODAYS DATE:REFERRED BY:BIRTH DATE:REASON FOR VISIT: PLEASE ANSWER All the QUESTIONS AS ACCURATELY AS POSSIBLE. IF YOU DO NOT UNDERSTAND

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To fill out please answer all of, follow these steps:

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Start by reading each question carefully.

03

Provide accurate and complete information for each question.

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If a question is not applicable to you, indicate N/A or Not Applicable.

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