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Get and Sign Blood Cancer Report 2014-2022 Form
Female # of Children ______________
Check if you have ever had:
Arthritis
Diabetes
Asthma
Epilepsy
Cancer
Heart Trouble
Other, please explain:
High Blood Pressure
Kidney Trouble
Peptic Ulcer
Poliomyelitis
Rheumatic Fever
Tuberculosis
Check if any member of your family has ever had:
Arthritis
Diabetes
High Blood Pressure
Asthma
Epilepsy
Kidney Trouble
Cancer
Heart Trouble
Peptic Ulcer
Other, please explain:
Poliomyelitis
Rheumatic Fever
...
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