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Medical History: Information will remain confidential

Have you ever been admitted to a hospital?



Have you any of the following illness(Tick where appropriate)

a. Tuberculosis of the chest infection?



b. Fits, nervous disease or fainting attacks?



c. Allergies to foods or drugs?



d. Diabetes Mellitus?



e. Mental Illness



f. Asthma?



g. Gynecological and obstetric disorder?