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Part One TO BE COMPLETED PRIOR TO MEDICAL APPOINTMENT Sex Male Female Name Date of Exam MEDICAL AND SURGICAL HISTORY any ER visits or hospitalizations CURRENT MEDICATIONS Attach a second page if needed Medication Name Dose Frequency Diagnosis Prescribing Physician Specialty Date Medication Prescribed Allergies/Sensitivities Smoke y / n How much Alcohol y / n How much Drugs y / n IMMUNIZATIONS Tetanus/Diphtheria every 10 years Hepatitis B / Flu Shot Other specify Pneumovax OTHER...
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