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New Medical Information
In the past 3-5 months where have you been treated?
Do you have medical insurance?
Have you been diagnosed with a new illness?
Have you returned to work in any capacity?

In the box below, please add DETAILS about all new medical visits that you have had in the past 3-5 months. Include the following: doctor/hospital/ clinic name and address; dates of treatment or admission; reason for treatment(s) and condition(s) treated or diagnosed. New medications or changes to medications. 

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