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HISTORY FORM Name D. O. BToday s Date Primary doctor and any other doctors whom you want to receive progress notes from University Cancer Specialists List name address phone number Medications Name of Medication Dose of Medication How often do you take it Medication Allergies Pharmacy Name Number Past Surgeries and Dates Type of Surgery Date of Surgery Surgeon Name/Location Present Illnesses check all that apply Diabetic High Blood Pressure Heart Disease Thyroid Disease Asthma Arthritis.
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