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Medical History

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Name
Are you a smoker?
Are you an alcohol user?

Do you have any of the following symptoms?

Chest pain:
Breast diseases:
Seizure:
Heart problems:
Thyroid problems:
Tooth problems:
High blood pressure:
Hepatitis C:
Emotional problems:
Diabetes:
Kidney problems:
HIV:
Cancer:
Asma:
Eye problems:
Problems with bleeding: