Place of birthCity: blanks Country: blank .
Height:Ft.(or Meter)blanks Inch(or Cm) blank .
Weight:Lb blanks or Kg blank .
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Your Desired Expectations
Current main concerns
List all surgical procedures in the past and their date:
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Past Medical diagnoses and dates of diagnosed:
List all allergies and age it started:
List of past medications:
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List of current medications:
Family Medical History:
Check any current conditions or those that you have had in the past (please state which conditions you have only had in the past and are no longer present in the comment box).