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MEDICAL RECORD - EUROBRIDGE 2009

Name:
Surname:
Do you currently suffer from any illness?
If yes ,please give details:
Are you allergic to anything?
If yes ,please give details:
Do you require a special diet?
If yes ,please give details (What products can you not eat?):
Have you suffered from any fractures or injuries?
If yes ,please give details:
Do you have any problems related to sleeping? (Incontinence,Sleepwalking etc.)
If yes ,please give details:

Blood Group:

Medical History (Operations, hospital visits etc.)
Do you suffer from fainting?
Do you have asthma?
Do you suffer from regular hemorrhages?

Have you had the triple vaccine injection? (tetanus, diptheria, whooping cough).

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

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