1 Date. / / I Date: / /
/ 2. Have you had any significant changes to your / health since your last physical exam? If so, / please explain them below.
/ 3. Do you exercise regularly? Yes cd No □ \
/ 4. /s your home tobacco and smoke free? Yes d No □ \
/ 5. When was the last time you had more / ... / funny pictures :: auto
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