BAY AREA NEUROSURGERY, P.A.
813 S. Parsons Avenue
Brandon, FL 33511
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PATIENT HEALTH HISTORY
TEMP
BP
WGT
P
Patient Name: First
M.I.
Last
Date of Birth:
/
/
Height:
ft.
in.
Right Handed:
Left Handed:
Prior treatments for current issue: ? Physical Therapy :
Pain Management:
Chiropractic Care:
Current problem due to: Car Accident:
Work Accident:
Accident:
Other:
Describe:
Past History: Please list any prior major illnesses and/or injuries
Surgeries/Hospitalization
YR
Outcome/Complication
Have you ever had problems with anesthesia? No:
Yes:
Describe:
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