Previous Medical History:

No Previous Medical Problems
Diabetes
Immune System Disorder
Hepatitis
Abdominal Electrocardiogram
Emphysema, Asthma or other Lung Disease
Siezure or Epilepsy
Heart Attack or Angina
Other (Specify)

Previous Surgery/Procedures:

None
Appendicectomy
Gallbladder Removal
Joint Replacement
Angioplasty
Cardiac Bypass
Hysterectomy
Valve Replacement
Other (Specify)

Current Medications:

None
Antibiotics (Specify)
Aspirin
Narcotics (Specify)
Digitalis/Dioxin
Insulin
Nitroglycerine
Steroids
Lasix
Phenobarbital
Other (Specify)

Allergies:

None
Antibiotics (Specify)
Aspirin
Medical/X-Ray Dye
Other (Specify)

Medical Devices:

None
Contact Lenses
Hearing Aid
Joint Replacement
Pacemaker
Artificial Heart Valve
Dialysis Shunt
IV Line/Shunt
Automatic Internal Defibrillator
Other (Specify)

Personal Information Attached:

None
ECG
Other Medical Image (Specify)

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