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Ation Arthritis / anti-inflammatory Asthma medication Other medication YES YES YES YES YES YES YES NO NO NO NO NO NO NO If YES, please indicate the following Medication Name Reason for Medication Dosage Duration on medication Possible relevant side effects Medical Clearance I feel that there are NO medical contra-indications to my patient undergoing a graduated exercise program. I feel that my patient is NOT able to participate in a graduated exercise program for the followi.

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