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Please Complete and Print these forms, ready for your visit. (Time Saver)
Have you had trouble with the following?

Cardiovascular   No   Respiratory   No
  Present Past No     Present Past No
Poor Circulation   Asthma
High Blood Pressure   Tuberculosis
Aortic Aneuryan   Shortness of Breath
Heart Disease   Emphysema
Vascular Disease   Cold/Flu
Heart Attack   Cough/Wheezing
Chest Pain    
High Cholesterol   Ears/Nose/Throat   No
Pace Maker     Present Past No
Jaw Pain   Dizziness
Irregular Heartbeat   Hearing Loss
Swelling of Legs   Sinus Infection
    Nosebleed
Genitourinary   No   Sore Throat
  Present Past No   Difficulty Swallowing
Kidney Disease   Bleeding Gums
Lower Side Pain    
Burning Urination   Eyes   No
Frequent Urination     Present Past No
Blood in Urine   Glaucoma
Kidney Stone   Double Vision
    Blurred Vision
Hemotologic/Lymphatic   No    
  Present Past No   Integumentary   No
Hepatitus     Present Past No
Blood Clots   Skin Ulcers
Cancer   Skin Disease
Easy Bruising   Eczema
Easy Bleeding   Psoriasis
Fevers/Chills/Sweats   Rashes

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