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St Anthony Family Medicine Center Patient Information Update Name: Date of Birth: Have there been any changes to your medications or doses since your last visit? YES / NO 1.____________________________________________________________ 2.____________________________________________________________ 3.____________________________________________________________ 4.____________________________________________________________ 5.____________________________________________________________ Have you been hospitalized since your last visit? YES / NO If yes, for what reason? ______________________________ Check any symptoms that you may be having: chest pain trouble breathing weight gain weight loss depression trouble urinating diarrhea constipation vomiting nausea headache fever rash vision changes hearing trouble weakness numbness easy bruising or bleeding fatigue other: ______________________________
