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Web07 The subject has a history of alcohol or substance abuse or dependence other than cigarette smoking within the past year 08 Use of any illicit drug or smoked marijuana in the last 3 months. 09 The subject is unwilling to be randomized into active or placebo conditions, or be available for follow-up assessments. WebMedication History Form Patient Name: Date: Allergies Name of Substance (drug or food) Type of Reaction Check if none Do you react to latex or rubber (gloves, balloons, etc.) with a rash, wheezing, etc.? hotel di kuala ibai
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