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Rections Duration of Therapy Diagnosis PLEASE LIST ALTERNATIVE THERAPIES THAT HAVE BEEN ATTEMPTED AND ANY OTHER PERTINENT INFORMATION RELATED TO DRUG AND/OR DISEASE STATE. IF NOT PRESENT, WITHIN NORMAL LIMITS WILL BE USED FOR THE REVIEW. Medication/Failure Reason: ESR:_______________ CRP:_______________ # Joints:_______________ Height:_______________ Weight:_______________ HA1C:_______________ Hemoglobin:_______________ Dialysis:_____________ %BSA:______________ BMI:_______________ .

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