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Get PATIENTNAME HOMEADDRESS EMAIL EMPLOYER TODAY'SDATE DATEOFBIRTH HOMEPHONE CELLPHONE SS#/SIN PATIENT

EDICAL HISTORY PHYSICIAN OFFICE PHONE DATE OF LAST EXAM YES NO 2. Have you been hospitalized for any surgical operation or serious illness? 4. Have you ever taken Fen-Phen/Redux? 5. Do you use tobacco? 6. Do you use alcohol, cocaine, or other drugs? 7. Are you wearing contact lenses? YES NO q q Local Anesthetics q q Barbiturates q q Aspirin q q or other q q Sedatives q q.

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