CURRENT SYMPTOMS: (select all that apply)
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PAST MEDICAL/SURGICAL HISTORY: (select all that apply)
PAST SURGICAL HISTORY: (select all that apply)
Please list other medications you are taking (include "over-the-counter' medicine and doses)
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Does anyone in YOUR FAMILY have the following illnesses? Please write in the specific relationship of a family member, i.e. Mother, maternal aunt, paternal uncle, sister.
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