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MEDICAL RECORD REPORT OF MEDICAL HISTORY NO. OF ATTACHED SHEETS DATE OF EXAM NOTE This information is for official and medically-confidential use only and will not be released to unauthorized persons 1. WEIGHT 9. ARE YOU Check one 8. PATIENT S OCCUPATION RIGHT HANDED LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON T KNOW Household contact with anyone with tuberculosis Shortness of breath Chronic cough Blood in sputum or when coughing Palpitation or pounding heart...

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