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Ar of last dose taken, if known) TETANUS FLU VACCINE(S) PNEUMONIA VACCINE HEPATITIS VACCINE Allergic To /Describe Reaction: OTHER Allergic To /Describe Reaction: LIST ALL MEDICINES YOU ARE CURRENTLY TAKING: Prescription and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). Include medications taken as needed (example: ). DATE NAME OF MEDICATION / DOSE DIRECTIONS: Use patient friendly directions. (Do not use medical abbreviat.

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