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MEDICATIONSPlease list all prescription and non-prescription medications, vitamins, home remedies, birth control, herbs etc.
ALLERGIESList all reactions to medicines, foods, and other agents.
PERSONAL MEDICAL HISTORY
HOSPITALIZATONS: Please list all prior hospitalizations and dates
Who lives at home with the patient?
Please indicate with a check (√) any current problems your child has on the list below.
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