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Medical History
Why do you need a Doctor /  what are your symptoms?
     
 
How long have you been experiencing these symptoms?
     
       
Have you been hospitalized for this problem? Yes No    
Check if You Have Any of the Following Medical Problems:
High Blood Pressure
Previous Heart Attack
History of Chest Pain
History of Heart Disease
Ulcers
Family History of Bleeding Problems
Asthma/Emphysema
Diabetes
Tuberculosis
Previous Cancer

Have You experienced any of the following?

Chest Pain Allergies  Heart Trouble Asthma Cancer
Anxiety Dizziness Diabetes Tension Insomnia
Headache Sinus Trouble Nervousness Vision Problems Numbness / Tingling
Epilepsy Growing Pains Neck Aches Depression Backache
High Blood Pressure Hepatitis Nausea / Vomit Rheumatism Ear Infections
Digestive Problems Loss of Memory Muscular Dystrophy Multiple Sclerosis Leg Pain
Arthritis Feet / Hands Cold ADD/ADHD Anemia Other
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