Health Maintenance – Prescreening
To help our doctors understand you better and to give you more time to gather your past medical history, please fill in the following form before your exam
e.g.: 12/2017 or 2017
-Bee Stings
-Advil, EPI pen
-Jethrix, 3x day
-Riladol, 1x day, as needed
-Appendicitis, 1988
-Pneumonia, 2018, hospitalization 2 weeks
Mother:
-COPD
-deceased, 74, lung cancer
-Brother, deceased, 22, rectal cancer
-Sister, illness, 42, breast cancer