Get PF-108 2010-2021
LOYER 4. SS# DATE OF BIRTH 5. FAMILY PHYSICIAN LAST VISIT 6. WORK ALLERGIES LAST HOSPITALIZATION 7. MILITARY SERVICE TYPE OF DISCHARGE 8. PERSONAL HISTORY Emotional Illness Alcoholism Drug Habit Headaches Cigarettes/Day Tuberculosis Pneumonia Stomach Problems Operations Nervous Disorders Stroke Heart Trouble Dizziness Hay Fever Blood in Urine Other Illness High Blood Pressure Meds taken Regularly 9. HISTORY OF BACK INJURY 10. FAMILY HISTORY 11. PHYSICAL EXAMINATION: HEIGHT WEIGHT VISION - DIS.
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