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Medical History Form

FLC Medical History Form

Name(Required)
Please select any of the following that you have had in the past or currently have.(Required)
Please select any of the following that your immediate FAMILY have experienced.
Please list any allergies you have (food, environmental, medication, & other), and explain the severity of each. Please also list symptoms you experience when exposed to allergens. If you have no allergies, please type "no allergies."*