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PAST MEDICAL HISTORY

Have you had any symptoms in the Fever Lung Eyes Muscle Unexplained weight loss

following areas in the past 6 months: Neurological Psychological Urinary Ear, nose, throat Stomach or intestinal

Immunological Heart Infection Skin

Briefly Explain:

Have you ever been diagnosed with or treated for any of the following:

Diabetes Heart or Vascular Disease High Blood Pressure

Arthritis Rheumatoid Arthritis Cancer

Kidney Disease Liver Disease Other: ____________________

List all medications that you are currently taking: __________________________________________________

List all allergies:

____________________________________________________________________________

Past Surgical History: ___________________________________________________________________________

Do you smoke?

____________

If so, how much?

________________________

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