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The below named physician for the purpose of claim processing. Signed (Patient): 1. History: (a) When did symptoms first appear or accident happen? (b) Day patient ceased work because of disability? Date: Date: / / / / (c) Has patient ever had same or similar condition? If yes, state when and describe ( )Yes ( )No (d) Is condition due to injury or sickness arising out patient's employment? ( )Yes ( ) No (e) Is condition due to automobile accident, indicate state in which it occurred.

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