2100 Lynn Road, Suite 205 ● Thousand Oaks, CA 91360
Phone (805) 497-3585 Fax (805) 497-1313
Patient Name:
Referred By:
Date Completed:
CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
MEDICAL HISTORY:
Have you ever been told that you have had any of the following illnesses?
|
YES |
NO |
IF YES, DESCRIBE? | |
| HEART DISEASE | |||
| HYPERTENSION | |||
| STROKE | |||
| HIGH CHOLESTEROL | |||
| HIGH TRIGLYCERIDES | |||
| HIGH BLOOD SUGAR | |||
| CANCER | |||
| KIDNEY FAILURE | |||
| VASCULAR DISEASE | |||
| ANY SURGERIES | |||
| ANY OTHER ILLNESSES |
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