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Adult Health History
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Name:___Date:___ Whatisyourimpressionofyouroverallhealth?(circle one) ExcellentGoodFair
Age___years Height___inchesGender:___Male___Female___OtherPoorWeight___poundsPreferredpronouns:___Haveyouhadorhaveyoueverexperiencedanyofthefollowingconditions?
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Information such as personal medical history, family medical history, current medications, allergies, and past surgeries must be reported on wwwcourseherocomadult-health-history-form-10adult health history form-10.
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