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Brain Tumor Center Health History Questionnaire

PATIENT QUESTIONNAIRE
HISTORY AND PHYSICAL
This question requires a valid date format of MM/DD/YYYY.
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Allergies / Contraindications
Have you ever had an allergic reaction to any medication (including IV contrast dye or iodine) or food? If yes, please list medication or food and reaction: *This question is required.
Are you currently taking any medication? *This question is required.
Medications
Please list any medications (presciption and over the counter) you are currently taking (including vitamins and aspirin):
Preferred Laboratory: *This question is required.
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Form #60109