Complete Physical Exam for Patients of Dr. Mike Lewiecki

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Name

FAMILY HISTORY (List any blood relatives with the following problems)

IMMUNIZATIONS AND TESTS (Give date you have most recently had each of these)

PLEASE CHECK TO INDICATE ANY RECENT SYMPTOMS

GENERAL
EYES
ENT
ENDOCRINE
RESPIRATORY
CARDIOVASCULAR
GASTROINTESTINAL
UROLOGICAL
NEUROLOGICAL
SKIN
HEMATOLOGICAL
MUSCULO-SKELETAL
OSTEOPOROSIS
MALE ONLY
FEMALE ONLY