MEDICAL FORM 1. Are you allergic to any medications?__________ If so, what?______________________________________ 2. Please list any other allergies:_________________________________________________________________ 3. Have you ever had surgery?__________ Have you ever been hospitalized?____________________________ __________________________________________________________________________________________ 4. Please list any disabilities or handicaps:__________________________________________________________ __________________________________________________________________________________________ 5. Are you under the care of a physician for any medical problems?_____________________________________ __________________________________________________________________________________________ 6. Do you take medication(s)?_________ If so, please identify:_______________________________________ 7. Do you have any special medical needs that we should know about?_________________________________ Please specify:_______________________________________________________________________________ _________________________________________________________________________________________
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