State of Illinois Health Examination Form.pdf

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State of Illinois Health Exam.pdf
Yes No Tobacco use (type, frequency)? Yes No. Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No. Dizziness or chest pain with. exercise?

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Certificate of Child Health Examination 2015.pdf
Heart problem/Shortness of breath? Yes No Tobacco use (type, frequency)? Yes No. Heart murmur/High blood pressure? Yes No Alcohol/Drug use? Yes No. Dizziness or chest pain with. exercise? Yes No Family history of sudden death. before age 50? (Cause?)