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Health Questionnaire for People Living in the Regio n Served by the CSSS Who Do Not Have a Family Physician Important information Conditions: You do not have a family physician.
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Health History Questionnaire No Are you being treated for any conditionnow Yes No Do you carry a special health card or bracelet Yes No Have you ever had any of the following: Heart trouble.
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AIRSIDE STAFF PRE-EMPLOYMENT HEALTH QUESTIONNAIRE The following questionnaire is to determine if you have any illnesses, injuries or health problems which may be adversely affected.
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HAVE YOU EVER USED TOBACCO TRY ASKING YOURSELF THESE 10 QUESTIONS 1. Have you ever tried to quit but couldnt 2. Do you smoke NOW because it is really.
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... Questionnaire Patient Name:__________ _ Date of Birth: Age:_______ Have you ever ...
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NAME ADDRESS HEALTH Childhood: Measles Mumps Chicken Pox Diabetes Adult Have you had any serious illness Have you ever been hospitalized.
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