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STANDARD HEALTH EXAMINATION RECORD
Date 1 _______
Name White Peter
last first
Age 2 _______
Sex M
Address 14 Market Street, London
3 _______
Have you had any problems with
(check *)
Frequent colds *
Frequent sore throats *
Allergies
Operations
Stomach upsets
Convulsions
Diabetes
High blood pressure*
Bad headaches *
Chicken pox
Measles
Mumps
Other
List of medications you are now taking 4 _______
Allergies to medications none
09/06/07
47
MEDICAL HISTORY
Penicillin (injections), gargle