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General Information

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Telephone:		(xxx) xxx-xxxx
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Medical History

Are you being treated or have your been treated for any of the following?
If yes, past or present, please click appropriate boxes and list medications prescribed:

Any other condition not mentioned

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	Past	Present
Allergies
Anaemia
Asthma
Birth Control
Deep Vein Thrombosis / Blood Clots
Depression
Diabetes
Drug Dependance
Heart Problems
Hormone Replacement
Jaundice

Psychiatric Illness