MISCELLANEOUS:
Yes No
Trouble from an anesthetic (used in surgery).
Been told to have an operation and not had it done.
Received treatment with X-rays, cobalt,
radium or “atomic cocktails" ...
.
Have you been hospitalized for any ilness? wees
In past year, have you been bothered with
hay fever, asthma or hives?
.
Have you ever had an allergic reaction “from taking
a medicine or from medicine used to take X-rays? .
Break out from adhesive tape, soap or detergent ..
Were you born with any problems t% hat interfere
with your daily life? ....
oo
Received treatment for nervous or mental iliness. .
Had a serious iliness in a foreign country.
Have any household pets..
wo
X-RAYS:
Chest . 2. 2. 2 6 ew ew ee kt we et we te
Stomach or colon .....+.e «ee eee
Gall bladder. . . 1... 1 we ew ee we tte
Extremities .
2...
6
ew
we
ee
et
ew
te
tt
te
Back
.
a
2
.
»
a
*
*
>
*
.
*
.
.
2. 1
2. 6. 2
0
6
we
©
ew
ew
tw
ew
et ee wt
ew we tt
et
tlt
kt
ltl
kl
tl
ht
tlt
.
Teeth .
Other .
ECG:
®
*
.
.
*
e
*
tt
lt
Have you ever had an electrocardiogram? .
IMMUNIZATIONS:
Have you had
Smallpox vaccination within last 7 years ....
Tetanus shots (not antitoxin, it lasts 2 weeks) .
Polio shots within last 2 years ..... 2. ees
s
Unknown