| Document Date: 2008-11-20 20:03:33
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IndustryTerm health insurance / food / / MedicalCondition Sexually Transmitted Disease / tumor / High Cholesterol / Infection/Abscess / Persistent cough / injury / Obesity / Cancer / heart attack / COPD / Disease / Epilepsy/Seizures / valve disorder / HIV/AIDS / Diarrhea / Swollen lymph glands ALLERGIES / Arthritis / High Blood pressure / Tuberculosis Please list ALL allergies / Stroke / Heart Disease / Diabetes / Asthma / / MedicalTreatment joint replacement / surgery / Kidney Dialysis / Kidney Transplant / blood transfusion / / Organization Female Military Service / Alaskan ___Elementary School ___Asian ___Middle School / / Person Scarlet Fever / / Position Care Provider ___Yes ___No Current Dentist / / Product Tylenol / Actonel / Boniva / Fosamax / Zometa / Cardizem / Aredia / / ProvinceOrState Zip / Technology x-ray / Dialysis / /
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INTAKE AND ASSESSMENT Please answer the following questions to the best of your ability. FAMILY HISTORY Has anyone in your family had any of the following conditions? CONDITION