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Text in this example:
Dietary Supplement Diary Name of Supplement How Often Amount
500 mg , 1 tablet, etc. Reasons for Taking: Name Age Date Are you currently taking or have you recently taken any over-the-counter medications (e.g., aspirin, cold medicine, stool softener, pain reliever, etc.)? YES NO If Yes, list medications: What prescription medication(s) are you currently taking, if any?