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Get IL IL444-4737 2012

skin test positive (past/present)? Yes* Seizures? What are they like? Yes No TB disease (past or present)? Yes* No *If yes, refer to local health department. No Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No Family history of sudden death before age 50? (Cause?) Yes No Yes No Dizziness or chest pain with exercise? Eye/Vision problems? _____ Glasses Contacts Last exam by eye .

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