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Date of last medical checkup Physician What tablets pills liquids do you take regularly That includes uoride aspirin vitamins alcohol etc. Do you use tobacco Y N If yes for how long circle one or both if applicable Smoke Chew Have you ever or are you now taking biphosphonates Such as or Y Do you have or have you had any of the following diseases or problems Stomach or digestive upset or distress ulcers Rheumatic fever heart murmur Heart trouble heart attach stroke High blood pressure Low...
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To fill out the name of the patient, follow these steps:
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Start by writing the patient's first name.
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