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Or dead). o o o o Blood clots legs/lungs/eyes (circle all that apply) o Diabetes (high blood sugar) High blood pressure/stroke o Tuberculosis (TB) infection/disease High cholesterol o Breast or Ovarian Cancer Osteoporosis Nurse's Comments: Section 2: Personal Medical History If you are here for yourself, check all the boxes that apply to you now or in the past. If you are here for your child, check all the boxes that apply to your child now or in the past. o o o o o o o o o o o o o o o o.

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