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Secure Online Medical History Form

At North Star Medical, we use the most advanced security measures to protect your personal informationyour information is encrypted right at your computer, before it even travels across the Internet.

North Star Medical Weight Management

Medical History

Do you have a history of the following diseases:

YES NO
High Blood Pressure
Diabetes
Kidney Disease
Anemia
Hypoglycemia
High Cholesterol

Others...please list

Height: Weight: Age:

Please list your current medications and the dosages
(please include vitamins):


If you have allergies, please list them:

Patient First Name
Patient Last Name
Address
City
State
Zip Code
Phone
E-mail

Please enter your name again as your electronic signature.

Patient's signature:  
Today's Date: August 21, 2017

I accept the above information as true once submitted.



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