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TUCSON FAMILY MEDICINE HEALTH HISTORY FORM MRN Date: MEDICAL H STORY DOB: ... Frequency PLEASE LIST ANV MEDICATIONS YOU ARE ALLERGIC TO AND THE REACTION: Medication Reaction PLEASE LIST ANY CHRONIC MEDICAL PROBLEMS AND/OR SURGERY YOU HAVE AND/OR HAD, EVEN AS A CHILD (Such as diabetes, high blood pressure, cancer, heart … ................
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