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Get Standard Form 600 2010-2024

__ Have you ever received the smallpox vaccine? 2. GENDER: 4. Have you ever had a serious problem after smallpox or other vaccination? Yes No Unsure If YES; Explain: ________________________________________________________________________________________________ ______________________________________________________________________________________________________________ 5. Do you have a current illness with fever? Yes No Unsure 6. Are you allergic to any of these products: polymyxin B.

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