Fillable NEW PATIENT MEDICAL QUESTIONNAIRE (Advance Biomedical Treatment Center)

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NEW PATIENT MEDICAL QUESTIONNAIRE (Advance Biomedical Treatment Center)

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The NEW PATIENT MEDICAL QUESTIONNAIRE (Advance Biomedical Treatment Center) form is 1 page long and contains:

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File type: PDF

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ECCQ0119
Name: _______________________________________________ Date of Birth: ______________
NEW PATIENT MEDICAL QUESTIONNAIRE
Current Medical Problems:
1. _____________________________________ 5. ______________________________________
2. _____________________________________ 6. ______________________________________
3. _____________________________________ 7. ______________________________________
4. _____________________________________ 8. ______________________________________
Past Medical / Surgical History:
1. _____________________________________ 5. ______________________________________
2. _____________________________________ 6. ______________________________________
3. _____________________________________ 7. ______________________________________
4. _____________________________________ 8. ______________________________________
Current Medications (include dosage):
1. _____________________________________ 5. ______________________________________
2. _____________________________________ 6. ______________________________________
3. _____________________________________ 7. ______________________________________
4. _____________________________________ 8. ______________________________________
Current Supplements/Vitamins/Herbs/Homeopathic remedies:
1. _____________________________________ 5. ______________________________________
2. _____________________________________ 6. ______________________________________
3. _____________________________________ 7. ______________________________________
4. _____________________________________ 8. ______________________________________
Allergy to Medications: ___ YES ___ NO
If Yes, what? ______________________________________________________________________
Family Medical History: Medical problems
Father ___ alive ___deceased ___________________________________________________
Mother ___ alive ___deceased ___________________________________________________
Brother/s ___ alive ___deceased ___________________________________________________
Sister/s ___ alive ___deceased ___________________________________________________
Children ___ alive ___deceased ___________________________________________________
Grandparents:
Father-side ___ alive ___ deceased ___________________________________________________
Mother-side ___ alive ___ deceased ___________________________________________________
Others: ___ alive ___ deceased ___________________________________________________
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NEW PATIENT MEDICAL QUESTIONNAIRE (Advance Biomedical Treatment Center)

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Completed 25 May 2021

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