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    How to Fill in Our Adult Health History Form

    Listed below is a section-by-section guide through our Adult Health History Form:

    Review of Symptoms

    This section helps bring any symptoms you are currently experiencing to your doctor’s attention. Your symptoms may be due to a known diagnosis or indicate a new health issue.
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    Medications

    Please include the name, dosage and how often you take any medication. List both medications you take regularly and occasionally. Please also include any over-the-counter medications, vitamins, supplements and herbal products you take. If the space provided is not sufficient, please use a separate sheet of paper.

    • Over-the-counter medications: Many former prescription medications are now available over-the-counter. Safe use of these medications depends on your age, other medications you take and your health history.
    • Vitamins: Commonly used vitamin and mineral supplements include calcium, vitamin D, iron, vitamin B-12, niacin, folic acid and multivitamins. Please list any of these and others that you take. Your doctor will discuss which ones are most important to your health.
    • Supplements and herbal products: List any supplements or herbal products you take as they can cause adverse reactions, interact with any other drugs you take and affect lab results.

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    Allergies or reactions to medications

    Provide the medication name and the type of reaction you had. Your doctor needs this information to consider whether you had a true allergic reaction or a non-allergic adverse reaction.
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    Immunizations

    If possible, obtain documentation from your previous doctor. If you do not have the exact immunization dates, please provide your best date estimate or a date range (for example: 2006 to 2010).
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    Health Maintenance Screening Tests

    This list covers a wide range of ages and genders and does not include all screening tests available. It’s unlikely that you need all the tests listed. The information you provide is a useful starting point for your doctor, so please include as much information as you can.
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    Personal Medical History

    For patients in good health, this section is easy to complete. If you have a more complex medical history, attach a separate sheet of paper with your diagnosis and relevant details. For example: Diabetes, type 2, started in: 2003. You do not need to repeat your medications here.
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