Popcorn workers - Medication Form

Spectrum of Flavoring Chemical-Related Lung Disease

Appx K1_Medication.ENG

Popcorn workers - Medication Form

OMB: 0920-0979

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Appendix K.1: Medication Form (English)











































Form Approved

OMB No. 0920-xxxx

Expires xx/xx/20xx


Medication Form


In the table below, please list prescription and non-prescription (over-the-counter) medicine that you take on a regular basis. Please fill out the table below and bring this with you to your appointment.


Name: ______________________________________




Name of medicine


Dose

When taken

(such as daily, twice a day, as needed)














































Please list any medicine allergies: _____________________________________________________



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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleBuilding Related Asthma Research in Public Schools (New)
Authorsqg8
File Modified0000-00-00
File Created2021-01-29

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