| Document Date: 2014-03-14 13:58:50
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Company PATIENT REVIEW OF SYSTEMS / / IndustryTerm chemicals / / MedicalCondition tumor / Abdominal pain / rheumatism / Pain/cramps/numbness / Pneumonia / Cancer / HIV / Chest pain / tendency Cancer / disease / gastric ulcer / UROLOGY Kidney disease / Kidney disease / esophageal hernia / Thyroid disease / arthritis / Shortness of breath / unusual disease / seizures Head injury Stroke Paralysis / Emphysema / heart Fainting / Stroke / Nausea / nephritis / Pleurisy / Diabetes / Muscle pain / o______ Urinary tract infection / breast disease / High Cholesterol / Gout / Food allergies / Heart Attack / Osteoporosis / AIDS / consciousness Convulsions / infection / Parent None Meditation None No Problem Insomnia Sleepwalks Falls Asleep Immediately Hx Sleep Apnea / Blood disease / High Blood Pressure / hepatitis / IMMUNIZATION HISTORY Flu Pneumonia Hepatitis / cyst / FAMILY HISTORY Medical Illness / o______ Kidney stones / Back pain / Joint pain / Chronic bronchitis / wheezing / Tuberculosis / Asthma / / MedicalTreatment radiation treatment / IMMUNIZATION / Blood transfusion / Cardiac catheterization / Heart Surgery / Vascular Surgery / Lung Surgery / dialysis / / Organization Heart and Lung Center / / Person Son(s) Brother / / Position seizures Head / / ProvinceOrState New Jersey / / Technology radiation / x-ray / dialysis / /
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DEBORAH® Heart and Lung Center 200 Trenton Road Browns Mills, NJ[removed]CONFIDENTIAL MEDICAL QUESTIONNAIRE REASON FOR VISIT: