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MYVIRTUALMEDIC
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Medical History Form
First name
*
Last name
*
Email
*
Birthday
Day
Month
Month
Year
Phone
*
Address
What is your health concern today?
*
Tell us more about your health concern
*
Upload any documents to explain further
Upload File
Do you smoke?
*
Yes
No - ex-smoker
No - never smoked
Other - Vape
Other
Do you drink alcohol?
No
Yes
If Yes to alcohol intake, how much do you drink in a week?
Family history
*
How would you like us to help you today?
*
Submit
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