Medical Health Questionnaire - My Doctor Online The Permanente ...
Medical Health Questionnaire - My Doctor Online The Permanente ...
Medical Health Questionnaire - My Doctor Online The Permanente ...
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PERSONAL SURGICAL HISTORY (continued)<br />
Hip surgery YES NO<br />
Hysterectomy (ovaries removed) YES NO<br />
Hysterectomy (ovaries left) YES NO<br />
COMMENT:<br />
COMMENT:<br />
COMMENT:<br />
Knee surgery YES NO COMMENT:<br />
Neck surgery YES NO COMMENT:<br />
Tubal ligation YES NO COMMENT:<br />
Spleen removed YES NO COMMENT:<br />
Other<br />
MEDICATIONS<br />
NAME DOSE DIRECTIONS<br />
DRUG ALLERGIES<br />
DRUG NAME REACTION<br />
Member <strong>Health</strong> History<br />
© 2012 Kaiser <strong>Permanente</strong> — All Rights Reserved DRAFT FORM No. XXX<br />
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