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Health Check Medical History Form

Gender :
Age :
Please tick the approprite option
1. Personal History
1 Do you smoke/chew tobacco/snuff? / day for years
2 Do you consume alcohol? / day for years
3 Is your urination normal?  
4 Are your stools normal?  
5 Are you married? Children
6 Do you exercise regularly?  
7 Diet?  
2. Past History   Duration
1 Allergy(Any particular drug)?
2 Diabetes?
3 High Blood Pressure?
4 Coronary Heart Disease?
5 Tuberculosis(TB)?
6 Asthma?
7 Thyroid Problem?
3. Family History
4. Have you undergone any operation/procedure
    before? Please specify, if any
5.Current Treatment/Medications
    Please specify, if any
6. Present Health complaints