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Name * Date
Address * Phone # *
Date of Birth
Height Weight
Indicate by checking any diseases or illnesses you have or have had:
Asthma Allergies Arthritis HBP
Back Cond Fatigue Joint Pain LBP
Bursitis Ulcers Heart Cond. Sinus
Hernia Epilepsy Eye Cond. TB
Diabetes Hearing Anxiety Vertigo
Paralysis Migraines Depression Thyroid
Drug Use Alcohol Use Bronchitis Pneumonia
SOB Skin Rashes Hay fever Weight Loss
HIV Hernia
Have you ever been hospitalized for any of the above or had surgery? Explain:
Have you ever had an industrial accident? Explain:

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