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Fax:  (907) 569-1433

Patient Portal

Patient History Form

Patient History

 

Family History

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Personal Social History

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Smoking

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History of Injectable Drug Use

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Previous Procedures

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Past Medical/History Problems

 

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Hospitalizations / Surgery



List all medicines, birth control pills, or vitamins you take with or without a prescription including over the counter drugs. (e.g. Aleve, Tagamet 200. etc) Include herbs and aspirin.