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MEDICAL INFORMATION Date: Name: Age: DOB: PAST MEDICAL HISTORY Please check off illnesses or conditions you have had: Diabetes Glaucoma Heart Trouble Cancer High Blood Pressure Hepatitis HIV Vein
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Start by carefully reading each option listed under "Please check off illnesses".
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If you or the person filling out the form have any of the listed illnesses, mark the corresponding box next to it.
03
If none of the listed illnesses apply, leave all boxes unchecked.
04
Double-check your selection to ensure accuracy.
05
Once you have finished checking off the appropriate illnesses, proceed to the next section of the form or submit it as required.

Who needs to please check off illnesses:

01
Individuals who are completing a medical or health-related form that includes a section for reporting illnesses.
02
Patients visiting a healthcare provider who might be required to provide information about their medical history or current health status.
03
Individuals participating in research studies or clinical trials where detailed information about their health conditions is necessary for proper evaluation and assessment.
04
Students or employees who are filling out health-related forms for school or work purposes, such as insurance or fitness evaluations.
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Please check off illnesses is a form used to report any illnesses or medical conditions that may affect an individual's ability to perform certain tasks or duties.
All employees are required to fill out please check off illnesses to disclose any existing illnesses or medical conditions.
Employees must provide accurate information about their illnesses or medical conditions on the form provided by their employer.
The purpose of please check off illnesses is to ensure that employers are aware of any medical conditions that may affect an employee's ability to perform their job safely.
Employees must report any illnesses, medical conditions, or disabilities that may impact their work performance or require special accommodations.
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