Family Practice Associates

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Social Educational and Work History

Do you drink alcohol?
Are you a current smoker?
Are you a former smoker?
Are you sexually active
Are you concerned that you may have been exposed to HIV?
Selected Value: 0

Family Health History

Please list below the health history of your blood (genetic) first degree relatives

Review of Symptoms

Please review the following symptoms and circle those items that are a problem for you

Disease Prevention and Health Maintenance

Please list below the most recent dates of vaccines and health screening tests
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I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.
Date / Time