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Home
Services
Preventive Care
Pain Control
Lab
Travel Medicine
Cardiovascular Health
Breast Health
Dense Breast. Are You Dense?
Cancer Screening
Ultrasound
Are you at risk?
NextGen Diagnostics
FAQs
Contact Us
Our Cause
Menu
Home
Services
Preventive Care
Pain Control
Lab
Travel Medicine
Cardiovascular Health
Breast Health
Dense Breast. Are You Dense?
Cancer Screening
Ultrasound
Are you at risk?
NextGen Diagnostics
FAQs
Contact Us
Our Cause
Full Name
Phone Number
Email
Date of Birth
Address
Gender
Male
Female
Marital Status
Single
Married
Divorced
Widow
Medical Insurance
Allergies
Do you use or do you have history of using tobacco?
Yes
No
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Mammogram
EKG
Past Medical History
High Blood Pressure
Heart Attack
Chest Pain
Palpitations
Skip Beat
High Cholesterol
Diabetes
Type I
Type II
Thyroid Disease
Asthma
COPD
Cancer
Leg Pain/Cramps
Anemia
Kidney Disease
Are you currently taking any medication?
Yes
No
If so, please list:
Acknowledgement
Patient acknowledges and agrees that Nex Gen Preventive Care, along with their assigns, will be entitled to use any data, discoveries, results, improvements or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications or commercial purposes. All data will be kept on a Cloud Based system that is password protected, and accessible to Next Gen Preventive Care staff.
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