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Revised 11/21/16Medical History QuestionnaireName: Date of Birth: Sex assigned at birth: Male FemaleHeight: Weight: What Complaint(s), Symptom(s), and/or change(s) in your treatment caused you to
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What is revised 112116?
Revised 112116 is a form used for reporting specific information to the relevant authorities.
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Entities and individuals who meet certain criteria set forth by the authorities are required to file revised 112116.
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