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John Doe DOB: 1/30/79 Primary Medical History: Diabetes, High blood pressure, Sarcoidosis Prior Surgical History:

Knee replacement (1999), Left inguinal hernia repair (1982) Allergies: Penicillin (rash), Amoxicillin (anaphylaxis throat closing, lip swelling) Current Medications: Hydrochlorothiazide (25 mg daily), Emergency Contact: Jane Doe (wife), 555-555-5555 or 222-222-2222.

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