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ADD/ADHD Anxiety Arthritis Asthma Back problems Blood disorder/anemia Bone/joint problems Cancer Cardiac problem Chest pain/shortness of breath Females only Abnormal pap smear Irregular periods Chicken pox (Year? Female surgery Are you on medication for cramps or regulation of periods? Explain conditions checked: _______________________________________________________________________________________________________________________

Are you currently taking any medications? _________________________________________________________________________________________________________________________ Do you have any drug allergies? ___ Yes Do you have any other allergies? Have you ever been admitted to a hospital? _________________________________________________________________________________________________________________________

 

 

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