Please fill up the forms as completely as you can.
List any medications you take (including oral contraceptives, over the counter medications and home remedies:)
List any of the following that you have had
Have you considered:
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Please note any family history (parents, grandparents, siblings, children; living or deceased) for following conditions:
High Blood Pressure
Do you drive?
If yes, do you have difficulty when driving?
Do you use tobacco products?
Do you drink alcohol?
Ear, Nose, Mouth, Throat
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