1. Do you have or have you had any of the following conditions?
2. List any past illness or surgery for which you were hospitalized.
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3. List and describe any allergies to medications and other substances.
4. List any current medications (include prescription and non-prescription drugs)
If yes, please provide us with names and phone numbers below:
May we leave personal medical information on your:
My signature below indicates I have received and/or reviewed a copy of the Privacy Practice Policy of this office and have agreed to the release of my health information as indicated above.
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