PRE-OPERATIVE PATIENT QUESTIONNAIRE

TRIAL FORM 056-11-07 11/01/07 EXP03/08 pg 2 of 2 rev. 08/11/08; 9/2/08; 9/7/08 PRE-OPERATIVE PATIENT QUESTIONNAIRE PRE-OPERATIVE PATIENT QUESTIONNAIRE (continued) DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING:If yes please check box Chest pain, heart attack or other heart problems Heart irregularities or palpitations ................
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