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Medical Health Form <br />Address: <br />Date of Birth: Occupation: <br />List all the medications you have been taking in the last 6 month <br />Hare you taken any of the following in the last 2 days; Aspirin, Ibuprofen, Alcohol? <br />Have ycu received chemotherapy or radiation treatment in the last year? <br />Name of DDcfor: <br />Surgery <br />Allerc ies: have you ever had an allergic reaction to any of the following: <br />Aniib of c ointments /Medi uthin Latex Rubber Nuts <br />Medicatior Metals Hair dyes <br />Dn-gs Foods Lidocaine <br />Paint 5 Crayons Glycerine <br />Anesthetics (which <br />Otr er alergies (Ii <br />Are you presently pregnant or breast feeding? <br />MRI :czn scheduled in the next 3 <br />Laser or IP_ scheduled in the next 3 months <br />