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Student Medical History
Student Medical History
First Name
*
Last Name
*
Student Number
*
Allergies (note reation)
Diagnosed Medical Conditions (current and past)
Surgeries
Medications (include prescription, over the counter, vitamins, herbal supplements)
Family History
Do you have a family physician?
*
Yes
No
Name of Physician
Are you under the care of a specialist?
*
Yes
No
Name of Specialist
Reason
Substance Use
Smoking
Quit Smoking, how long ago?
Marijuana
Alcohol
Other Substances
Other Pertinent Information
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