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X-Ray, Nuclear Medicine study for your current problem?
□ No □ Yes
If Yes, what did it show?
Do you have a history of cancer?
□ No □ Yes
If Yes, what kind of cancer?
□ No □ Yes
Chemotherapy □ No □ Yes
If Yes, did you have treatment for the cancer?
If Yes, what kind of treatment?
Other
□ No □ Yes
Radiation therapy
□ No □ Yes
Please explain _________________________________
List any operations you have had and the dates:
Do you have a history of any of the following medical...
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