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on date :24-03-18

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1 Do you have any family history of :
a) Heart ailment
b) Diabetes
c) Mental illness
d) Tuberculosis
2 Whether you have undergone any surgical operation in the past?
3 Do you take medicines regularly?
4 Do you have any body deformity or defect?
5 Do you have any problem of Rheumatism / Asthma / Joint pain?
6 Do you have any large veins in your legs, thighs (varicose -veins)?
7 Are you color blind?
8 Do you have any hearing problem?
9 Have you ever had any skin disorder?
10 Have you ever had medical treatment for?
a) Allergies
b) Hay fever
c) Reaction to surgery
d) Reaction to medicine
e) Sprain
f) Fracture or broken bone
g) Diabetes
h) Fits
i) Eye trouble
j) Fainting spells
k) Heart troubles or High Blood Pressure
l) Hernia or Rupture
m) Injury to knee joints
n) Paralysis or weakness in arms or legs
0) Emotional upsets
p) Tuberculosis
q) Rheumatism
r) Prolonged fever
s) Back pain
t) Sacroiliac
u) Any other health condition

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