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Get Beaumont Health Evaluation Pre-Placement History and Physical Screening

ARTMENT ZIP LAST 4 DIGITS of SS # DATE OF BIRTH LOCATION HOME TELEPHONE NO. E-MAIL ADDRESS CELL NO. PAST MEDICAL HISTORY Please ✓ below if you have ever had or are currently under treatment for any of the following: 1. Anemia/Sickle Cell Anemia 12. Epilepsy/Seizure 23. Numbness/Muscle Weakness 2. Arthritis/Joint Pains 13. Eye Problems/Contacts/Glasses 24. Speech Defects/Hearing Loss 3. Asthma/COPD 14. Gallbladder Problems 25. Scoliosis/Curvature of Spine 4. Back Pain/Back Prob.

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