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Medical History

Fill all required fields (★) to submit the form.

Patient details:

Dr
Mr
Mrs
Ms
Miss
Other:

Smoking History:

Current
Previous
Passive smoking

Alcohol:

Job(s):

Weight:

Stable

Current medications:

Past medical history:

Pets at home:

No
Yes

Asbestos exposure:

No
Yes

Snoring:

No
Yes

Feeling tired/sleepy during the day:

Motor vehicle accidents associated with sleepiness in the past?

No
Yes

Respiratory symptoms:

Cough
Phlegm
Wheeze
Shortness of breath
Chest Tightness

Live:

Alone
With
I agree that I have answered these questions to the best of my ability.

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