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MEDICAL DIAGNOSIS

Enter Disease Primary:

Enter Disease Secondary:

Enter Disease Tetiary:

MEDICATIONS BEING USED

DOSAGE FORM

Tablet - Solid-Forms Liquid-Forms Semi-Liquid Gaseous Patches

DOSAGE ADMINISTRATION

Oral Injections Application

Medications Taken:

Medications Taken:

Medications Taken:

Medications Taken:

SELECT TRIAL PHASES
Name of Study Enrolled/Participating In:

Initial Study
Phase 1
Phase 2
Phase 3
Phase 4
Continous Study

CHECK SYMPTOMS BEING EXPERIENCED

Headache

Pain

Vomiting

Coughing

Shivering

Other Reactions:

Other Reactions:

Other Reactions:

REACTIONS TO MEDICATION BEING TAKEN AND DEGREE

Cold

Headache

Pain

Vomiting

Coughing

Shivering

Itching

Other Reactionary Attribution

Other Reactions:

Other Reactions:

Other Reactions:

DESCRIPTIONS of CONDITIONS and SYMPTOMS

AGE

0-10
10-20
20-30
30-40
40-50
50-60
60-70
70-80
80-90
90+

Gender Identification

Male Female Non-Binary

Race

White Black Asian American Indian Pacific Islander

Ethnicity
African American European Asian Middle East
Hispanic

Contacts:

Telephone Number 4057628422 Email Addressorighoye.dennis@gmail.com

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