COMPREHENSIVE NEUROLOGY SPECIALISTS

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Medical Questionnaire Cont

Have you ever had problems with anesthesia?

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Family History Check if any blood relative has had any of the following. Indicate which relative in the "Notes" section.

Diabetes
Heart Disease
Seizures
Allergies
Meniere's Disease
Stroke
Asthma
Migraines
Alcoholism
Cancer
Arthritis
Glaucoma
Osteoporosis
Anemia
Thyroid Problem
High Blood Pressure
Mental Illness
High Cholesterol
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