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MEDICAL RECORD - EUROBRIDGE 2009

Name:

Surname:

Do you currently suffer from any illness? Yes No

If yes ,please give details:

Are you allergic to anything? Yes No

If yes ,please give details:

Do you require a special diet? Yes No

If yes ,please give details (What products can you not eat?):

Have you suffered from any fractures or injuries? Yes No

If yes ,please give details:

Do you have any problems related to sleeping? (Incontinence,Sleepwalking etc.) Yes No

If yes ,please give details:

Blood Group:

Medical History (Operations, hospital visits etc.)

Do you suffer from fainting? Yes No

Do you have asthma? Yes No

Do you suffer from regular hemorrhages? Yes No

Have you had the triple vaccine injection? (tetanus, diptheria, whooping cough). Yes No

Do you have any other illnesses or wish to add anything?

Documentación Parque Natural de Cazorla
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- Ficha Médica >>
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