Patient Name ...

Yes No Persistent cough, Coughing up blood? 11. Yes No Excessive thirst? Yes No Bleeding problems, Bruising easily? 12. Yes No Headaches? Yes No Sinus problems/Seasonal allergies? 13. Yes No Dry mouth? DO YOU HAVE OR HAVE YOU HAD: NO . FOR ALL: _____ Yes No Heart surgery/Artificial Heart Valve? 25. Yes No HIV? ................
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