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Full name: Sex: Age: ID Card No./Passport No.: Issued on: In: Current address: Reason for examination: DISEASE PREHISTORY OF OBJECT FOR EXAMINATION
Anyone in your family has one of following diseases: contagious disease, heart disease, diabetesmellitus, tuberculosis, bronchus asthma, cancer, epilepsy, mental disorder, other…..?
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Do you have one of following diseases: contagious disease, heart disease, diabetesmellitus, tuberculosis, bronchus asthma, cancer, epilepsy, mental disorder, other…..?
………………………………………………………………………………………………………. ……………………………………………………………………………………………………….
No
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Height: 167 cm Weight: 57 kg BMI index: 20 Pulse: 80 times /minute Blood pressure: 110/70 mmHg Health classification: Type I
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