Yes Gonorrhea or Syphilis... . Anemia. .« 2. « s © © © © we we Jaundice. . . 2. ee sw we we Epilepsy. ... ran Migraine headaches. cee ee Tuberculosis. . . 6 « s «6 6 Valley Fever. . 2... 2 eee Diabetes. . 2... ee ew we Cancer. . 2. 2. 2 ee ee es High blood pressure or low blood pressure ....... Parasites, worms, amoeba. .... ° Cy Nervous breakdown .....- Food, chemical or drug poisoning. Hay fever or asthma ..... Hives or eczema .... . Frequent infections or boils. Frequent colds or sore throats. Any other disease ...... ALLERGIES: Penicillin or sulfa..... Aspirin, codeine or morphine. Mycing or other antihiatics Mertniolate or Mercurochrome. Any otner drug. ....... Any foods... . 2... 2a Adhesive tape. ....... Nail polish or other cosmetics. Tetanus antitoxin or serums . INJURIES: Broken or cracked bones... Sprains . 1. 2. 6 we ew ee ee Lacerations .. 1... «eee Dislocations ......e-. Concussion or head injury . Have you ever been knocked unconscious? cs ee ee * + TRANSFUSIONS: Blood or plasma transfusion . SURGERY : Tonsillectomy ... 1... ee ee Cancer or malignant tumor... ., Non-cancerous disease .... Removal or loss of a finger, * toe, No Unknown