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Medical History Name DOB // Date // What is the reason for today s visit Are you allergic to any medication If yes please list medications and reactions below Yes No Are you pregnant Yes No Please list below current medications you are taking including prescriptions over the counter meds vitamins herbal supplements etc Have you ever had a history of I have had no significant medical problems- Yes AIDS Alcoholism Asthma Anorexia Arthritis Bleeding Disorder Breast Lump Bronchitis Bulimia...
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