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Address Reason for Visit Have you seen another doctor for this Who and when Injury related Yes No Job related Date of Injury Symptoms Onset ALLERGIES Latex Allergies Blood Test to Confirm Environmental List Drug Allergies Food Allergies List all drug allergies and type of reaction MEDICATIONS Attach list if more than ten prescription medications Do you take Daily Aspirin etc. Daily Ibuprofen Steroids Home Oxygen Vitamins Other OTC Supplements Any metal implants/devices PLASTIC AND...
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Ted A. Jackson MD is a medical doctor specializing in cardiology.
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