| Document Date: 2009-11-20 22:38:59
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IndustryTerm insurance coverage / Insurance name_________________________________________ / insurance / / MedicalCondition Miscarriages / infertility / PMS ___skin lesions/disorders ___stroke ___tendonitis / ___headaches / hepatitis A / dosages______________________________________________________ Drug allergies / insomnia / GERD / fatigue / ___heart failure / ___high blood pressure ___headaches / joint pain ___kidney disease / cancer / ___eczema/psoriasis / chest pain / fibromyalgia / genital herpes / attack/Stroke Diabetes Asthma Hay Fever Thyroid problems Depression / COPD/emphysema ___constipation ___depression ___diabetes / erectile dysfunction / Other allergies / stomach ulcers / hemorrhoids / back pain / migraine / ADHD ___anxiety ___allergies ___anemia ___arthritis ___asthma / / MedicalTreatment Birth control / / /
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Microsoft Word - Synergy Patient Registrationforms101809.doc