PATIENT DETAILS
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𝐈 𝐡𝐚𝐯𝐞 𝐟𝐢𝐥𝐥𝐞𝐝 𝐭𝐡𝐢𝐬 𝐟𝐨𝐫𝐦 𝐰𝐢𝐭𝐡 𝐜𝐨𝐫𝐫𝐞𝐜𝐭 𝐦𝐞𝐝𝐢𝐜𝐚𝐥 𝐢𝐧𝐟𝐨𝐫𝐦𝐚𝐭𝐢𝐨𝐧 𝐚𝐧𝐝 𝐚𝐠𝐫𝐞𝐞 𝐭𝐨 𝐬𝐡𝐚𝐫𝐞 𝐭𝐡𝐢𝐬 𝐰𝐢𝐭𝐡 𝐭𝐡𝐞 Dr HE Clinic 𝐓𝐞𝐚𝐦. *
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Full Name *
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Where did you find us? *
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Date Of Birth *
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MEDICAL CONDITIONS
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Diabetes or blood sugar problems
Thyroid problems
Heart problems / conditions
Lung problems / conditions
Blood pressure problems
Kidney problems
Liver problems
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Previous / current history of cancer
HIV or AIDS
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Neurologic problems
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