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Get Rush-Copley Adult Medical History

__________________________________ ____________________________________________________________________ Please list your current prescription medicine, over-the-counter medications, vitamins, supplements, and herbal products you take regularly (you may use the back of page 3 if needed) Medication/Supplement Name Dose How often Reason for Medication/ supplement Health History – Please check if appropriate and indicate how many years present Years present Condition ___________ Arthritis ___.

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