Personal Health Form
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Name of Applicant *
Applying for *
Do you have any health problems? *
If the answer is yes, please explain what kind.
Do you need a special diet? *
If the answer is yes, please explain what kind.
Are you using any type of medication? *
If the answer is yes, please explain what kind.
Do you have allergies *
Did you have any other health problems which are not listed above?
Please explain and comment.
If the answer is yes, please explain what kind.
Have you ever had or do you have any of the following:     *
Yes
NÂO
Skin conditions                         
Eye trouble                               
Ear trouble                               
Head injury                              
Recurrent headaches               
Epilepsy 
Fainting Spells                          
Mental or nervous disorder       
Weakness 
Insomnia
Stomach / Ulcer                             
Hay fever / Asthma                        
Heart Trouble                               
High blood pressure                       
Low blood pressure                        
Rheumatism / Arthritis                  
Back Problems                              
Sexually Transmitted Disease      
Broken Bones
Veneral Disease
Pedras na vesícula
Shortness of Breath
Tumor or Cancer
Appendicitis
Jaundice
Tumor ou Câncer
Hepatitis
Intestinal trouble
Recurrent diarrhea
Diabetes
Kidney Disease
Anemia
Other 
Surgery on the following
Tonsillectomy
Hernia repair                              
Appendectomy 
Gall bladder
Other
If the answer is yes, please explain or comment.
Did you have any of the following sicknesses?
Only for women
Yes
No
Severe cramps                          
Irregular Periods
Are you pregnant
Clear selection
If the answer is yes, please explain what kind.
Are you now under doctor's care for any condition? *
If the answer is yes, please explain what kind.
When was your last medical exame? *
Date maybe approximate.
MM
/
DD
/
YYYY
Any physical handicaps or health conditions which require special attention *
If the answer is yes, please explain or comment.
How are you doing with your weight? *
yes
No
Below
Above
What is your Blood Type *
How would you rate your health condition *
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