Year 1 Medical History Questionnaire
Personal Medical History
Sections 6-8
Section 6: Surgical History
36. Please list any other surgical procedures you have had in the past that were not described in a previous question.
Type of Surgery
Date (month/year)
Reason
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Section 7: Hospitalization History
37. Please list any other hospitalizations of 24 hours or more not described in a previous question.
Reason for hospitalization
Date (month/year)
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-
-
-
Section 8: Other Health Information
38. Please use this space to record any other personal health information that was not listed above.