| 1. Is this person allergic to Doxycycline, Tetracycline or any other 'cycline' drug? |
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| 1a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication? |
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| 2. Is this person allergic to Ciprofloxacin or any other “floxacin” drug? |
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| 1a. Has person experienced respiratory (breathing) or cardiac (heart) arrest after taking this medication? |
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| 3. Does this person have seizure disorder or epilepsy? |
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| 4. Is this person taking Tizanidine (Zanaflex ©)? |
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| 5. Does this person have difficulty swallowing pills? |
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| 6. Does this person have renal (kidney) disease or Myasthenia Gravis? |
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| 7. Is this person pregnant? |
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Yo, el suscrito, certifico que toda la información anterior es correcta de acuerdo a mi conocimiento. Por la presente autorizo al receptor de este documento a compartir esta información con los organismos de salud pública al nivel local, estatal y federal con el fin de garantizar la efectividad y seguridad del medicamento. Se me ha ofrecido una copia del Aviso de Prácticas de Información. |