Msneny.org
Other auto-immune diseases (e.g. lupus, Sjogren’s, Crohn’s, etc.) ___ ___ Any other conditions that run in the family ___ ___ If your parents, siblings, or any children have died, at what age, and from what causes? 4. MEDICATION ALLERGIES, SENSITIVITIES, OR INTOLERANCE: Medication Reaction 5. CURRENT MEDICATIONS: ................
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