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CHECK-LIST HOW TO COMPLETE: Do I take any medication? Sleeping pills or tranquilizers? Do I have intolerance
to drugs? Allergies? Had I ever undergone
surgery? Do I sleep badly? Do I get tired easily? Headaches? Vaccinations not up to date? Chest pains during physical Palpitations? High blood pressure? Abnormally short of breath? Do I bleed too easily? Asthma? Bloody spits? Lumbago or sciatica? Jaundice, hepatitis? A gastric or duodenal ulcer? Parasites or intestinal worms? Often constipated? False
needs? Red or black blood in stools? Do I faint easily? Was my birth difficult? Memory loss? A history of depression? Tremor, clumsy hands? Nephritic colic? Urinating several times at
night? Diabetes, sugar in urine?
Bouts of dizziness? A buzzing sensation in my
ears? Prolonged colds or sinusitis? Is my voice hoarse? Swollen glands? Exposure to toxic substances? After-effects of an accident? Likelihood of being HIV positive? WOMEN ONLY Bleeding between periods?
My answers will be covered by medical confidentiality. NAME: NAME AT BIRTH: FIRST NAME: Age Height Weight kg Today's date from |
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