MEDICAL/PHYSICAL HISTORY REPORT FORM

§ 06 Pain § 07 Discharges of all kinds § 08 Head § 09 Ears § 10 Eyes § 11 Nose § 12 Mouth and tongue § 13 Teeth § 14 Throat § 15 Eating and Drinking § 16 Nausea, Vomiting, Eructations, etc. § 17 The Stomach § 18 Abdomen § 19 Urine and urination § 20 Stool, Diarrhoea, Constipation § 21 Anus, Rectum, Piles § 22 Lungs and ... ................
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