Medical History
Christopher Maloney, N.D.
docleroymaloney@hotmail.com
4 Drew St., Augusta ME 04330 (207) 623-1681

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How did you hear about me?

Current concern

What brought you here today?
What is its history? 
What other health issues affect it?
When does it happen? How long does it last?
What have you tried already? Did anything help?
What would you like me to do for you when we meet?

I, __________________________ give Christopher Maloney, ND permission to receive information about my health history and to discuss my history with other doctors involved in my treatment with the understanding that he will maintain my trust and respect my confidentiality in all situations. Signed_______________________________ Date________

I LOOK FORWARD TO WORKING WITH YOU!