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Past Medical History: Do you have or have you had any of the following: (please circle answers) Diabetes Yes No High or Low Blood Pressure Yes Cancer Yes No Stroke Yes Heart Disease Yes No Arthritis/Gout/Rheumatism Yes Convulsions Yes No Blood Disease Yes Hay Fever or Asthma Yes No Venereal Disease Yes Lung Disease Yes No Have you ever had a blood Yes No transfusion? Are you taking or have you ever Yes No taken steroids for any reason? Current Medications: Name Dosage Frequency Yea.

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  • applicable
  • Convulsions
  • Venereal
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  • Thyroid
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