5SCPTAG2_00

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Select Medical Condition: NoneAbnormal EKGAddison'sAdrenal InsufficiencyAlzheimer'sAnginaAsthmaAtrial FibrillationCataractsCongestive Heart FailureContact LensesCOPDDeep Vein ThrombosisDementiaDiabetesEmphysemaEpilepsyFibromyalgiaGlaucomaHeart PatientHemophiliaHypertensionHypoglycemiaLupusLymphedemaMitral Valve ProlapseMultiple SclerosisPacemakerParkinson'sRenal FailureRheumatoid ArthritisSeizure DisorderStent ImplantVision Impairedvon Willebrand's

Select Medical Condition #2: NoneAbnormal EKGAddison'sAdrenal InsufficiencyAlzheimer'sAnginaAsthmaAtrial FibrillationCataractsCongestive Heart FailureContact LensesCOPDDeep Vein ThrombosisDementiaDiabetesEmphysemaEpilepsyFibromyalgiaGlaucomaHeart PatientHemophiliaHypertensionHypoglycemiaLupusLymphedemaMitral Valve ProlapseMultiple SclerosisPacemakerParkinson'sRenal FailureRheumatoid ArthritisSeizure DisorderStent ImplantVision Impairedvon Willebrand's

Select Food/Drug Allergy: NoneAspirinAdhesive TapeBee StingsCephalexinCephalosporinClindamycinCodeineContrast DyeErythromycinFentanylIodineLatexLidocaineMorphineMorphineSulfateNitrous OxideNovocainePenicillinPhenerganPrinzideRobinulShellfishStadolSuccinylcholineSulfurSulfaTetracyclineVersedWasp Stings

Select Food/Drug Allergy #2: NoneAspirinAdhesive TapeBee StingsCephalexinCephalosporinClindamycinCodeineContrast DyeErythromycinFentanylIodineLatexLidocaineMorphineMorphineSulfateNitrous OxideNovocainePenicillinPhenerganPrinzideRobinulShellfishStadolSuccinylcholineSulfurSulfaTetracyclineVersedWasp Stings

Select Food/Drug Allergy #3: NoneAspirinAdhesive TapeBee StingsCephalexinCephalosporinClindamycinCodeineContrast DyeErythromycinFentanylIodineLatexLidocaineMorphineMorphineSulfateNitrous OxideNovocainePenicillinPhenerganPrinzideRobinulShellfishStadolSuccinylcholineSulfurSulfaTetracyclineVersedWasp Stings

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Select Current Medications: NoneAccuprilAltaceAmarylAtenololAvaproCaptoprilCefzilCellceptCelebrexCoumadinDepakoteDesmopressinDexamethasoneDiflucanDigoxinDilaudidDiovanHCTDyazideEffexorEnalapril MaleateGemfibrozilGlipizideGlucophage XRGlucovanceGlyburideGlucotrolHydrochlorothiazideHydrocodoneHyzaarImuranIsosorbideLevoxylLipitorLisinoprilMetoprololMetformin HCLNortriptylinePlavixPrednisonePrilosecPrografSodium PentothalSpironolactoneSynthroid TrileptalVerapamilZestoreticZocorZyprexa

Select Current Medications #2: NoneAccuprilAltaceAmarylAtenololAvaproCaptoprilCefzilCellceptCelebrexCoumadinDepakoteDesmopressinDexamethasoneDiflucanDigoxinDilaudidDiovanHCTDyazideEffexorEnalapril MaleateGemfibrozilGlipizideGlucophage XRGlucovanceGlyburideGlucotrolHydrochlorothiazideHydrocodoneHyzaarImuranIsosorbideLevoxylLipitorLisinoprilMetoprololMetformin HCLNortriptylinePlavixPrednisonePrilosecPrografSodium PentothalSpironolactoneSynthroid TrileptalVerapamilZestoreticZocorZyprexa

Select Current Medications #3: NoneAccuprilAltaceAmarylAtenololAvaproCaptoprilCefzilCellceptCelebrexCoumadinDepakoteDesmopressinDexamethasoneDiflucanDigoxinDilaudidDiovanHCTDyazideEffexorEnalapril MaleateGemfibrozilGlipizideGlucophage XRGlucovanceGlyburideGlucotrolHydrochlorothiazideHydrocodoneHyzaarImuranIsosorbideLevoxylLipitorLisinoprilMetoprololMetformin HCLNortriptylinePlavixPrednisonePrilosecPrografSodium PentothalSpironolactoneSynthroid TrileptalVerapamilZestoreticZocorZyprexa

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