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Bryan Physician Network General Health & Physical Form

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Patient Information

Gender
* Were you referred by someone other than your regular doctor?

Medical History

Have you had in the past or do you now have any of these health conditions? Please give a brief description if appropriate.

Surgery

Have you ever had problems with anesthesia?

Family History

Social History

Tobacco Use?
Alcohol Use?
Other Drug Use?
Do you have a Living Will?
Do you have a power of attorney for health care?

Allergies & Medications

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