PATIENT INFORMATION
Heart Failure. Angina/Chest Pain. Heart Attack: year_____ [ ]Pacemaker [ ] Ablation [ ]Defibrillator[ ] Stent [ ]By Pass Surgery. Heart Valve. Rheumatic Fever. Irregular Heart Rhythm. Blood Clots. Bleeding Problems. Varicose Veins. Anemia. Spina Bifida/Polio. ... Current living situation: With Spouse or Significant other With Relative/friend ... ................
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