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This happen? When? Where? What areas of your body were injured? When was your supervisor notified? 3. Allergies to medication? Please simply describe your reaction to the medication. 4. Present medications and dosages Print Form 5. Past medical history: A. Previous Surgery Gallbladder (Cholecystectomy) Appendix (Appendectomy) Replacement Artificial Knee (Total Knee Anthroplasty) Thyroid (Thyroidectomy) Kidney Replacement Artificial Hip (Total Hip Anthroplasty) Heart Bypass Stent.

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