NO NO IBS NO


Jun 19, 2017 - PLEASE COMPLETE THIS FORM AND RETURN IT WITH YOUR PRESCRIPTION. ALL. INFORMATION WILL BE HELD IN THE STRICTEST ...

RUTGERS HEALTH CENTER PHARMACY PATIENT INFORMATION FORM PLEASE COMPLETE THIS FORM AND RETURN IT WITH YOUR PRESCRIPTION. ALL INFORMATION WILL BE HELD IN THE STRICTEST CONFIDENCE. THANK YOU. PLEASE PRINT CLEARLY NAME: LAST

FIRST

MIDDLE INITIAL

DORM NAME & ROOM # (OR OFF CAMPUS ADDRESS): SEX:

□MALE □FEMALE

DATE OF BIRTH: STUDENT ID# PHONE #:

1. DO YOU HAVE ANY DRUG ALLERGIES?

□YES

2. DO YOU HAVE ANY CHRONIC CONDITIONS?

□NO

IF YES, PLEASE LIST BELOW

□YES

□NO

IF YES, PLEASE CHECK THOSE THAT APPLY:

□ASTHMA □GLAUCOMA □IBS

□DIABETES □HEART CONDITION □HIGH BLOOD PRESSURE

□OTHER: 3. ARE YOU TAKING ANY KIND OF MEDICATION, BIRTH CONTROL, AND/OR INSULIN AT THE PRESENT TIME?

□YES

□NO

IF YES, PLEASE LIST:

HOME ADDRESS AND PHONE NUMBER FOR OUR CONFIDENTIAL FILE (IF DIFFERENT FROM ABOVE):

ADDRESS: CITY:

PHONE #: STATE:

ZIP CODE:

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