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Carlos Gambirazio, M.D.Patient Name___Birthdate___/___/___ Todays Date ___Name of prior physician ___Name and # or location of pharmacy___What is the main concern that brings you in today?___ ___ Other concerns (list in order of importance)___Past Medical History Have you had or been treated for any of the following medical problems in the past (If yes, mark box and list approximate date of initial diagnosis) Date Date High blood pressure ___ GERD or heartburn ___ Irritable bowel syndrome ___...
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