New Patient History
Selected Value: 18
Medications / Dose / Times Per Day
Please check any that apply. Include the date and any abnormal results in the Other section, or bring it to your office visit.
Check every vaccine if you have received. Providing the date would be helpful. Include this information in the other section if you can.
Please include any Pregnancy Complications :
Please include in "other" the number and type of tobacco, packs per day, years of use. Include number of drinks and type. Birth Control type ( if used ) condoms, pill, vesectomy
How many hours a night ? Do you work the night shift ?
Please include the type / side / Date / and location of any previous or anticipated surgeries.
Example : J. Kaye / Internist / 01-01-1990
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+(805) 687-1505

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27 W. Micheltorena
Santa Barbra Ca. 93101

Open Hours

Mon-Fri 8:30am - 5:30pm Sat-Sun On Call