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16125 CAIRNWAY DR. SUITE 106
HOUSTON, TX 77084
281-855-1700
www.occmedicineclinic.com

MEDICAL HISTORY FORM

PERSONAL HEALTH HISTORY

CURRENT MEDICATIONS (Name, Strength, Frequency):
HOSPITALIZATIONS/SURGERIES :
Year Reason Hospital

Have you ever had any of the following? (Please check all that apply)

List any other medical problems :
Any Injuries :

REVIEW OF SYSTEMS
Do you currently have any of the following:

General Ear/Nose/Throat Gastrointestinal Musculoskeletal Psychiatric
SOCIAL HISTORY
Alcohol Do you drink alcohol?
If yes, how many drinks per week?  
Tobacco Do you currently use tobacco?
How many packs per day?
Chew # per day Pipe # per day Cigars # per day  
If you previously smoked, when did you quit?
How many packs did you smoke per day?
How many years did you smoke?
Drugs Do you currently use recreational or street drugs

OCCUPATIONAL HISTORY

I state that I have answered the questionnaire with information that is true and correct and to the best of my ability .


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