Document DvqbJ2b9eYEEkgw17z94Yja4M

13. RECENT MEDICAL HISTORY: i3A. 06.you consider yooraelt to : be in good health? ' Yfcs It-NO. state reason ___________ 13B." In the pest year, nave you developed:' tpitepsy? Rheoaatic fever? * Kidney disease? Bladder disease? Diabetes? Jaundice? `Cancer? ' . No -- ' Yeo _ Na_ 14h. If* you get a cold., does-it usually go to your-chest? (Usually means note than 1/2 the time);l. Yes ____ 2. No. _ J.yDon't get colds l$A; During the past year', have you had any chest illnesses that have Kept you ott work, indoors at hone, or-in bed?. 1.. Yes . _ 2: No-' 3. Does Not.Apply . . IP YES TO ISA: 1SB. Did you produce phlega with any of.these chest illnesses? ISC- In the past year, how many such' illnesses with (increased) pnleya did you have which lasted a wee* or aore? 16. RESPIRATORY SYSTEM : 1.' Yes ___ 2- No ___ 3- Does Not Apply _* Number of illnesses __ No such illnesses . . Jn the-past year have you bad: . Yes or. No Asthna Kuttbar Copgant on PobIUv. .- Answers Bronchitis Hay Peyer: Other Allergies BltUNO CODE 4810-tt-C .Phsuaonia Tuberculosis -Chest Surgery Other Dung Problem Heart Diseaso .-Do you have: -Frequent colds. Chronic, cough 'Shortness of breath when walking or cliabing one flight or stairs Do you: fTheese Cough up phiego Saoke cigarettes Date Yes of No Further Comment on-Positive Answers Yes or No:' ' Further comment on Positive Answers SO; < . Cl Z o Packs per day ____ Bow many years _ Signature . 2 fl ee Vd CD CD S' to GLEASON-OOIOOO