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Internal Medicine - Patient Forms

Please download, print and fill out the form(s) only if you have been requested to do so by a Dean Internal Medicine physician or their staff.

Bring the completed form(s) with you to your clinic visit. These forms are in PDF format. You will need Adobe Acrobat Reader to view these forms.

Patient History Form
This form is to be used by patients who are coming in for the first time for a physical exam.
For patients of Dr. Philip Bain, Dr. Robert Boyle or Dr. Pogorelova

Follow-Up Physical Questionnaire
This is to be used by patients who have already seen the physicians below for a fist time complete physical and are coming in for their yearly physical.
For patients of Dr. Philip Bain, Dr. Robert Boyle or Dr. Pogorelova

Pre-Operative Questionaire for Patients Undergoing a Surgical Procedure
This form is to be used by patients of the physicians listed below, who have already had a physical done by those physicians in the past, and who will be seeing them for a pre-operative visit before a surgical procedure.
For patients of Dr. Philip Bain, Dr. Robert Boyle or Dr. Pogorelova

Patients Being Seen for Headache

Initial Headache Evaluation
This form is to be used by patients who will be seeing Dr. Bain for a complete headache evaluation for the first time. Please make sure you have also filled out the Patient History Form if this is your first visit with Dr. Bain.
For patients of Dr. Philip Bain

Follow-Up Headache Visit Questionaire
This form is to be used by patients who have already seen Dr. Bain for an initial complete headache evaluation and will be seeing Dr. Bain for a follow-up visit for headache.
For patients of Dr. Philip Bain

 

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