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2017 Patient Name DOB Medication List Please list all prescription and non-prescription medications. Comprehensive Patient History Form Date Past Medical History check all that apply Acid Reflux Alcohol or Drug Problem Allergy problems Anemia Artery/Vein problems Arthritis Asthma Autoimmune disease Bleeding problems Blood clots Cancer Cataracts Colitis/Crohns Chronic pain Depression Anxiety Diabetes Esophagitis ulcers Fractures Gallstones Glaucoma Gout Headaches Heart disease Heart...
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