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?
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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
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Disease Prevention and Health Maintenance

Please list below the most recent dates of vaccines and health screening tests
Electronically Signed
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