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Health History Form

Please complete the form below so Dr. Tony and Dr. Craig can better understand your history and provide safe, personalized care.

Birthday
Month
Day
Year
Major Medical History
.
.
Do you take any of the following?
Are you allergic to Heparin?
Do you have a history of difficult blood draws or IV insertions?
Family History (Please check any illnesses that run in your family)
Social History
Smoking
Alcohol Consumption
Caffeine Consumption
Recreation Drugs
Have you had any tests or studies relevant to today's visit? if yes. please note these below:

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