Medical History Page 3
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5Drug or alcohol abuse
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Emotional or Psychological
Disorder______________________________________________________
Any other medical conditions
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Initial ____________
Have you ever had a reaction to: No Yes Describe
Penicillin
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Erythromycin
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Tetracycline
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Codeine
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Aspirin
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Acetaminophen
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Ibuprofen
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Sulfa
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Metals
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Latex
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Acrylic
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Other
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Do you use: No Yes Type Quantity
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