PAST MEDICAL HISTORY: []Rheumatic Fever []Scarlet Fever ...
Personal Past Medical History or Current Disease (s) (Please Circle if Yes): Skin Cancer Y N HIV/AIDS Y N. Actinic Keratosis Y N Hepatitis C/Liver Disease Y N. Melanoma Y N Thyroid Disorders Y N. Cancer (other than skin cancer) Y N Diabetes Y N. Psoriasis Y N Kidney Disease Y N ................
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