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Tacwerar DIET Survey
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bvipbAe MEMCAL 4 DET QUESTION NA (IRE
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PAGE Top &-
vale
S.2-0F
Re:
410112
SE 10"
Male
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et
Caasttontied
N2 7,22
Mapzy 25
AMLEDICAK H ISToRYy
flav Aen do you sully from " being sick just phin iflaess, whichover if may he 2
ED b Oncefuk
LI 4. Oncol4suanths
LT] 7. One{2 gears
LI 2. bruce Smart
a 5. Oneal b mndts
LI. Once/ % gears
oO
QZ b. Once} year
Wd
3. Once/2 ssumtes
fF
Quse/ # years
{hye qo Bey teeeived a medical pvauingtion or teedie al. eetinwad~ ofaug hid ? Ayes £7 No
Bf tos, where?
tezisne toopital C1 Eheye Ubepitel ID kivasabrin feprtel
Haine dean
nO an tp ifel J olds Gach Mraians { heolthatd
Have yr arer received ar X hay ? 7 tos JANe FEyes, ausewor te biloving puesttrns :
Has imag
chest K rays? TL]
boheve (hosgifs!)?
flow wei abtewie] X begs ? Z/ where Gospial) ?
Spinal K rugs?
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whee Lori!) ?
fy Stl, Xtag 9 Gumby) FT where Usspiti) 7
aye Hon Lie Heed 4 wnedical reefnent favolviag redtation Herapy 727ps ANo
Hype, answer Tee
oft ving gues Hed. ‘
None hues X tay skin heetrsulk ? £l whese 7
How nas Mypsid Hestireaite 7? LT whe?
fh
Han. yo nue hod radicachive crbstouces, ainjeced sobs You Ly a dele ? TT yes ff No
H YH, AnSwltp L, Mowing puttin
low Madan Fidney Seaus 2
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where 7?
how Maas Mie fuelrm tists ? id
WHY ?
oy old res yor Leh? 22
| dd is jo" swehis ? —aitie~
New
Leoord here any wnvgual medial or heh
problems
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