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Sentara Therapy  Form

Sentara Therapy Form

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(Conditions you now have or have had in the past.) Condition Onset Date Condition Onset Date Condition n Migraine headaches n Stomach or duodenal ulcer n Goiter n Seizures or convulsions n Hepatitis n Gonorrhea n n n Syphilis or VD n n n n n n n n n n n n n n n n n n n ___________ ___________ Stroke ___________ Polio ___________ Glaucoma ___________ Cataracts ___________ Blindness ___________ Recurrent ear infections ___________ Deafness ___________ Hay fever, allergic...
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