MEDICAL/PHYSICAL HISTORY REPORT FORM

Emphysema 72. Persistent or severe stomach pain 43. Pneumonia 73. Vomiting blood 44. Tuberculosis 74. Persistent or severe vomiting 45. Other lung or breathing condition 75. Hernia (rupture) LIVER, SPLEEN, & GALLBLADDER 76. Stomach or duodenal ulcer 46. ................
................