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Get and Sign Well Woman Exam Form 2010-2022
Smoke?
Mother
If yes, # per day
Brother(s)
Never smoked
Stopped (date)
Sister(s)
Has any blood relation (parent, brother/sister) had:
Heart Trouble/Stroke, Clots
Asthma/hay fever
High Blood Pressure
Cancer
Kidney trouble
PERSONAL MEDICAL HISTORY: Have you ever had or do you have now:
Abnormal Pap Smear
Alcohol/Drug Use
Anemia
Asthma/Hay fever
Bleeding disorders
Bloody urine
Cancer/Leukemia
Chicken Pox
Chronic cough
Convulsions
Diabetes
Dysentery
Eating...
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