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Please
indicate food
or drug allergies |
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Do
you suffer from depression? |
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Do
you have a history
of drug abuse?
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| How
many hours do you exercise per week: |
None 0-1 hours 1-2 hours
2-4 hours > 5 hours |
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| Do
you smoke? |
No Less than 1 Pack a Day 1 Pack a Day
2 Packs a Day More than 2 Packs a Day |
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| How
often to you consume alcohol? |
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Never Occasionally Daily |
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| Do you have a
family history of: |
Please describe type of
cancer: |
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(If more than one
hold down Ctrl key) |
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Cancer |
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(If more than one
hold down Ctrl key) |
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| Heart Disease |
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(If more than one
hold down Ctrl key) |
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| Liver Disease |
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(If more than one
hold down Ctrl key) |
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| Kidney |
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List all the surgeries you have ever had and the dates.
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List all the hospitalizations you have ever had and the dates.
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Please describe in great detail your current medical problems
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Please list all of the medications (generic
name) you are taking right now.
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Please enter any additional comments:
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Do you want to choose a doctor or do you want USMDDIRECT.com to choose one for you? |
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Please indicate which type of consultation you would like. |
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