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Patient Health Questionnaire

   

       

 



   

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Current Health Questions











Health History Questions. Please check "Yes" or "No" for each.

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
 

Medication Questions


Confidential Patient Questionnaire Agreement

To the best of my knowledge, all of the proceeding answers and information provided are true and correct. If I ever have any change in my health, or medications, or medical treatments I will inform the doctors at the next appointment without fail.