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