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MEDNET TECHNOLOGIES
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GENERAL HEALTH INFORMATION - 3 - Do you currently have any of the following complaints: Constitution Systems: Genitourinary: Unexpected Weight Change Yes No Painful urination Yes No (Loss or Gain) _____ Blood in urine Yes No Fever Yes No Incontinence or dribbling Yes No Fatigue Yes No Are youpregnant
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GENERAL HEALTH INFORMATION - 3 - Do you currently have any of the following complaints: Constitution Systems: Genitourinary: Unexpected Weight Change Yes No Painful urination Yes No (Loss or Gain) _____ Blood in urine Yes No Fever Yes No Incontinence or dribbling Yes No Fatigue Yes No Are youpregnant
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LAFAYETTE OB-GYN ADVANCED VEIN CENTER PATIENT REGISTRATION LAFAYETTE OB-GYN ADVANCED VEIN CENTER PATIENT REGISTRATION (Please Print) DATE_____ (office use) Physician: DJW JMH (circle) Acct #_____ PATIENT NAME_____ SOCIAL LAFAYETTE OB-GYN (ON-LINE) Page 2 PAST MEDICAL HISTORY Childhood illnesses ____routine (chicken pox, measles, mumps, etc.) ____unusual (describe):_____ List all serious MEDICAL ILLNESSES (requiring ongoing treatment and those requiring hospitalization.MEDNET TECHNOLOGIES
Dr. Leonardo - Medical Web Builder. WIth over 1,000 design layouts and more than 6,000 healthcare topics to choose from, Dr. Leonardo is a viable alternative to a custom website.MEDNET TECHNOLOGIES
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LAFAYETTE OB-GYN (ON-LINE) LAFAYETTE OB-GYN (on-line) Patient General History Form Physicians: Daniel J. Wickert, M.D. Jon M. Hoversland, M.D. DATE_____BIRTHDATE_____
MEDNET TECHNOLOGIES
Dr. Leonardo - Medical Web Builder. WIth over 1,000 design layouts and more than 6,000 healthcare topics to choose from, Dr. Leonardo is a viable alternative to a custom website.MEDNET TECHNOLOGIES
MedNet Technologies on Pinterest. Stay informed of the latest updates in the healthcare web development field. Join MedNet Technologies on Pinterest.MedNet Technologies on Pinterest. GENERAL HEALTH INFORMATION - 3 - Do you currently have any of the following complaints: Constitution Systems: Genitourinary: Unexpected Weight Change Yes No Painful urination Yes No (Loss or Gain) _____ Blood in urine Yes No Fever Yes No Incontinence or dribbling Yes No Fatigue Yes No Are youpregnant
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LAFAYETTE OB-GYN (ON-LINE) LAFAYETTE OB-GYN (on-line) Patient General History Form Physicians: Daniel J. Wickert, M.D. Jon M. Hoversland, M.D. DATE_____BIRTHDATE_____
MEDNET TECHNOLOGIES
Dr. Leonardo - Medical Web Builder. WIth over 1,000 design layouts and more than 6,000 healthcare topics to choose from, Dr. Leonardo is a viable alternative to a custom website.MEDNET TECHNOLOGIES
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LAFAYETTE OB-GYN ADVANCED VEIN CENTER PATIENT REGISTRATION LAFAYETTE OB-GYN ADVANCED VEIN CENTER PATIENT REGISTRATION (Please Print) DATE_____ (office use) Physician: DJW JMH (circle) Acct #_____ PATIENT NAME_____ SOCIAL LAFAYETTE OB-GYN (ON-LINE) Page 2 PAST MEDICAL HISTORY Childhood illnesses ____routine (chicken pox, measles, mumps, etc.) ____unusual (describe):_____ List all serious MEDICAL ILLNESSES (requiring ongoing treatment and those requiring hospitalization.Skip to content
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