Health Forms Series 3a

  

Complete the information in the form.

When was your last checkup?    
   
Put a check by problems you have had:  
allergies   asthma   cancer   diabetes   headaches  

heart attack   high blood pressuretuberculosis
       
Did you ever stay in the hospital?  Yes No  If yes, what for?  
surgery   illness   pregnancy   delivery  

other:  explain
     

What is your problem today?

    

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HeF3a2