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Bryan Physician Network Adult Health History Form

* Denotes required fields

Patient Information

Gender

My Last Exam Was

Hospitalization/Surgeries/Diagnostic Test

Immunizations

Are you currently updated on all immunizations?

Allergies or Reactions

 

Prescription, Herbal or Over-The-Counter Medications

Social History

Tobacco Use?
Alcohol Use?
Have you used street drugs?
Have you used IV drugs?
Are you afraid of anyone at home?

Menstrual History

Sexual History

 
My sexual preference is:
My current partner is:
Prior Venereal Disease
Multiple sexual partners

Family History

Has any Blood Relative ever had the following: (check all that apply.)

If Currently Living

If Currently Deceased

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