Medical History Questionnaire Questions. The questions below will be answered YES or NO. The last step in making the questionnaire is to input the questions.
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Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA).
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MEDICAL HISTORY QUESTIONNAIRE Name: Date of Birth: Emergency Contact: Sport: Sex: Phone Number What & When. The above questions have been answered completely and truthfully to the best of my knowledge. All questions contained in the questionnaire are strictly confidential and will become part of your medical record.
