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Permanent Residence: Birthplace: Chief Complaint Date of Last Physical: General Driver Athletic (Please complete the attached Pre-participation Physical Evaluation) Reason here to see clinician and describe nature, duration of symptoms: Review of Systems Do you have any problems or symptoms in the following areas: Head, brain, sensory (fainting, dizziness, unconsciousness, headaches, seizures, tremors) (Neurological): Heart, vessels, arteries, anemia Gastrointestinal (ble.

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