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HAVE YOU HAD ANY OF THE FOLLOWING DISEASES?
| Appendicitis |
Malaria |
Chicken Pox |
Alcoholism |
Influenza |
| Scarlet Fever |
Tuberculosis |
Diabetes |
Venereal Infection |
Pleurisy |
| Diphtheria |
Whooping Cough |
Cancer |
Arthritis |
Lumbago |
| Typhoid fever |
Anemia |
Heart disease |
Epilepsy |
Eczema |
| Pneumonia |
Measles |
Goiter |
Mental disorder |
Small pox |
| Rheumatic fever |
Mumps |
Polio |
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| OPERATIONS: |
Appendectomy |
Rectal |
Tonsillectomy |
Gall Bladder |
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Female organs |
Hernia |
Others: |
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| VACCINATIONS &
INJECTIONS: |
Small Pox |
Spinal Tap or
injection |
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Diphtheria |
Polio |
Tetanus |
Typhoid |
| ACCIDENTS OR FALLS: |
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| FRACTURES OR
DISLOCATIONS: |
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| Were you ever knocked
unconscious? |
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| HABITS: |
Sleep (hours) |
Coffee |
Tea |
Alcohol |
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Tobacco |
Exercise |
Drug/Medication |
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| Is any member of your
family ill or doctoring with any condition? |
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