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SignatureDate Relationship to patient Patient s Health History Anemia YES NO Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding YES NO Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur YES Hepatitis High Blood Pressure YES HIV Immune Sys Disorders YES Jaundice Kidney Disease Liver Disease Mental Disorders Mitral Valve Prolapsed YES Nervous Disorders YES Pacemaker Pregnant Pre-Medication Radiation Treatment YES...
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