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Patient Medical History Form

Have you been Diagnosed with any Neurological disorders?
Current Symptoms (Check all that apply)
Past Neurological History
Do you have history of HIV/Aids infection:
Do you have an Do Not Rescuscitate (DNR) Order?
Family Neurological History (Check all that apply):
Smoking History
Alcohol Use:
Drug Use (recereational or other):
Review of Systems (Please check any conditions you have expierenced recently:

Thank you for your submission.

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