• Patient Self Medical History

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  • Please note if applicable

  • Heart Failure

    Emphysema

    HIV/Aids

    Cancer

    Heart Disease/Attack

    Cough

    HepatitisA

    HepatitisB

    Angina

    Tuberculosis

    Liver Disease

    Hepatitis C

    High Blood Pressure

    Asthma

    Jaundice

    Artificial Joints

    Heart Murmur

    Hay Fever

    Rheumatic Fever

    Anemia

    Congenital Heart Lesion

    Sinus Trouble

    Blood Transfusion

    Jaw Joints Pain

    Artificial Heart Valve

    Sickle Cell Disease

    Arthritis

    Heart Pacemaker

    Stroke Epilepsy/Seizures

    Kidney Disease

    Pregnancy

    Heart Surgery

    Gastric Ulcers

    Diabetes

    Thyroid Disease

    Fainting/Dizziness

    Glaucoma

    Drug Addiction

    Psychiatric Disorder

    Recreational Drug Use

  • To the best of my knowledge, all of the preceding answers are true and correct. If there are any changes in my health/ medical conditions, I will notify the doctor immediately.

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