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Past Surgeries
Have you had an opereation on any of the following?

Illnesses
Check any of the following medications ypu are presently taking or have taken in the past year?

Medication
Have you ever had any of the following?

Hospitalization
If you have been hospitalized for any non-surgical illness, please list below (excluding childbirth).

Kidney & Bladder

Muscles, Bones & Joints

Nervous System

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