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Immunology / Immune system / Review of systems / Food allergy / Allergy / Post-nasal drip / Eczema / Sinusitis / Thyroid / Medicine / Anatomy / Health


Patient’s Name __________________________ Date of Birth____________________________ Today’s Date____________________________ Pharmacy Name and Location _____________________ __________________________________________
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Document Date: 2012-10-20 00:57:08

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Facility

Pharmacy Name / /

IndustryTerm

wood burning/gas/electric / /

MedicalCondition

pain / runny nose / fatigue / injury / Latex Allergy / glandular problem/thyroid disorder / frequent infections / chest pain / disease / headache / diarrhea / frequent sinus infections / shortness of breath / hives / Medication Allergy / cough / illness / constipation / depression / infections / nausea / eczema / anemia / respiratory infections / diabetes / itching / /

MedicalTreatment

Immunization / surgery / /

Position

General / /

ProvinceOrState

Mississippi / Colorado / /

Technology

X-ray / /

SocialTag