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Get Medical Health History Form for Annual Wellness Visit

E___________________________________ ____________________________________________ Today’s date__________________________________ 1. What is your age? Your date of birth_______________________________ 65-69. 70-79. 80 or older. 2. Are you a female or a male? Male. 7. During the past four weeks, what was the hardest physical activity you could do for at least two minutes? Female. 3. During the past four weeks, how much have you been bothered by emotional problems such as feeling anxious, .

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