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5. b. List any other substances to which you are allergic, including food, insect stings, etc. a. 6. c. b. c. List your last 3 hospitalizations, beginning with the most recent (excluding routine childbirth). Hospital/City: Reason: Month/Year: a. b. c. 7. List any operations you may have had which are not listed above. Hospital/City: Reason: Month/Year: a. b. c. 8. If a parent, grandparent, brother or sister has had any of the following diseases, check the appropriate box(es). (M -.

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