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Specifically, please place a check next to any of the following that you have had: Heart Disease Stroke Diabetes Hypertension Asthma Allergies Eczema Depression Sexually Transmitted Disease HIV / AIDS Tuberculosis (TB) Polio Cancer Major Trauma Page 2 of 6 Family History: Please Circle any of the following diseases tend to run in your family and list what relative (father, grandmother, etc.) Cancer: Heart Disease: Asthma: Stroke: Allergies: High Blood Pressure: Eczema: Seizures: Blood disorder: Diabetes: Social History: Please check beside any of the following you have used in the past or currently: Tobacco (cigarettes, cigar, pipe) Tobacco (chewing) Coffee Herbal Products Alcohol (beer, wine or spirits) Illegal Drugs Birth Control Pills Vitamins / Supplements Medications: List all of the Prescription Medicines or Over the Counter Drugs you are now taking: Allergies: Please list any medications to which you are allergic: Please list any foods that you are allergic or sensitive: Food Cravings: Please list any strong food cravings or favorite foods: Please list any strong food aversion or foods you avoid:
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