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Please tell us why you're here
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How did you find out about us?
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Allergies to Medicine?
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List Meds You're Allergic To
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List of Prescription Medications
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Medicine continued.
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Past Medical History/Diagnoses Given
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Mom and Dad Past Medical Problems?
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Please list any Surgeries you've had
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Do you Smoke? How Much? How Often?
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Drink Alcohol? How Much? How Often?
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Marital Status
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Number of Children/Ages
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Number of Children
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Are you pregnant or nursing?
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What type of work are you in?
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When was last Bloodwork drawn?
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