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Medical Form New Orleans
Problem or injury since your last evaluation?
Yes
No
Have you ever been restricted from physical activity?
Yes
No
Have you ever passed out or felt dizzy during or after physical exertion?
Yes
No
Have you ever had a seizure?
Yes
No
Have you ever had problems with vision?
Yes
No
Have you ever had problems with hearing?
Please explain all yes answers:
Acknowledgments
I affirm that the information given on this form is true and correct.
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