Images.pcmac.org
Do you now or have you ever had: ( Diabetes ( Heart murmur ( Crohn’s disease ( High blood pressure ( Pneumonia ( Colitis ( High cholesterol ( Pulmonary embolism ( Anemia ( Hypothyroidism ( Asthma ( Jaundice ( Goiter ( Emphysema ( Hepatitis ( Cancer (type) _____ ( Stroke ( Stomach or peptic ulcer ( Leukemia ( Epilepsy (seizures) ( Rheumatic fever ( Psoriasis ( Cataracts ( Tuberculosis ... ................
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