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Gender

Male

Female

Other

Age*

Symptoms*

Tried any medication?

Yes

No

Special Category

Allergies

Yes

No

Taking Prescription Medications

Yes

No

Medical History

Gender

Male

Female

Other

Age*

Special Category

Allergy

Immunizations

Questionaire

Gender

Male

Female

Other

Age *

Symptoms *

Tried any medication?

Yes

No

Special Category

Allergies

Yes

No

Taking Prescription Medications

Yes

No

Medical History

Gender

Male

Female

Other

Age

Special Category

Allergy

Immunizations

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Helping Patient and Pharmacist Inc.
5515 Argyle Street,
Vancouver, BC.
V5P 3J5

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