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CONFIDENTIAL HEALTH HISTORY The items below may relate to your current condition. In the space in front of each item enter if you currently have or ever HAD the problem. GENERAL Fever Chills Night Sweats Loss of sleep Fatigue Nervousness Weight Loss or Gain Allergies Bleeding Problem Anemia Diabetes Cancer Thyroid Disease/Goiter Alcoholism Drug Abuse HIV positive EYE EAR NOSE THROAT Poor Vision Pain in Eye s Deafness/Difficulty Hearing Nosebleeds Nose Problems Sinus Trouble Dental Problems...
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