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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