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At-Work Medical History Form
Medical History
Please fill in the following medical history questions.
Last Name
Have you experienced a major change to health within the past year?
Yes
No
Prefer Not To Answer
If yes, list who and what below:
Are you under the care of a physician or receiving ongoing medical care?
Yes
No
Prefer Not To Answer
If yes, list who and what below:
Name of Physician
Date of last medical visit:
If you are human, leave this field blank.
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