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* 1. Today's date --/--/----

Date / Time

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* 2. Date of Birth --/--/----

Date / Time

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* 3. Date of your surgery --/--/----

Date / Time

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* 4. Have you used products containing nicotine since your last visit? 

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* 5. Have you used alcohol since your last visit? 

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* 6. Have you been diagnosed with any new illness since your last check up? 

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* 7. Are you currently working?

T