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· List of Allergies: MEDICATIONS: Do you take any medications or vitamins regularly? Yes PAST SURGICAL HISTORY Do you have any past surgeries? Yes If yes, Please select all that

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Page 1: · List of Allergies: MEDICATIONS: Do you take any medications or vitamins regularly? Yes PAST SURGICAL HISTORY Do you have any past surgeries? Yes If yes, Please select all that

Page 2: · List of Allergies: MEDICATIONS: Do you take any medications or vitamins regularly? Yes PAST SURGICAL HISTORY Do you have any past surgeries? Yes If yes, Please select all that

Page 3: · List of Allergies: MEDICATIONS: Do you take any medications or vitamins regularly? Yes PAST SURGICAL HISTORY Do you have any past surgeries? Yes If yes, Please select all that

Page 4: · List of Allergies: MEDICATIONS: Do you take any medications or vitamins regularly? Yes PAST SURGICAL HISTORY Do you have any past surgeries? Yes If yes, Please select all that

Page 5: · List of Allergies: MEDICATIONS: Do you take any medications or vitamins regularly? Yes PAST SURGICAL HISTORY Do you have any past surgeries? Yes If yes, Please select all that

Page 6: · List of Allergies: MEDICATIONS: Do you take any medications or vitamins regularly? Yes PAST SURGICAL HISTORY Do you have any past surgeries? Yes If yes, Please select all that

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