PATIENT MEDICAL HISTORY
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Have you had any of the following and if yes please document date had procedure(s):
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SOCIAL HISTORY:
SOCIAL HISTORY:
Frequency:
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If Yes,
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Please check that apply and list diagnosis:
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Review of Systems
Review of Systems
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General
Ear Nose and Throat
Lymph
Respiratory
Cardiovascular
Gastrointestinal
Genitourinary
Gynecologic
Skin
Neurologic
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I, certify that this information is to the best of my knowledge and believe is true, correct and complete.
I give, CCSRM/Ahmed Khan, M.D., permission to release medical information to the above referring physician.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.