Get Kois Center Medical History 2012
_________________________________ Most recent physical examination _________________________________ Purpose __________________________________ What is your estimate of your general health? Excellent Good Fair Poor DO YOU HAVE or HAVE YOU EVER HAD: 1. hospitalization for illness or injury_______________________ 2. an allergic reaction to aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride metals (nick.
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