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CURRENT MEDICATIONS (PRESCRIPTION, OVER-THE-COUNTER, VITAMINS)

NAME OF MEDICATION

DOSE/MG

WHEN TAKEN

REASON

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

DRUG ALLERGIES

NAME

REACTION

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________

FEMALES ONLY

DATE OF LAST PERIOD

ARE YOUR PERIODS REGULAR?

_________________________

_____________

NUMBER OF PREGNANCIES

LIVE BIRTHS

MISCARRIAGES:

______________

_________

__________

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