How to write a Health Questionnaire? Download this Health Questionnaire template that will perfectly suit your needs.
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Have you or any applying family member been diagnosed as having or been treated for AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS-Related Complex) n Yes n No 7) Alcohol or substance abuse, mental/nervous disorders n Yes n No 8) Ulcer, colitis, difficulty swallowing, stomach problems, hernia or rectal problems n Yes n No 9) Diabetes, cystic fibrosis, albumin or sugar in the urine or other endocrine problems n Yes n No 10) Asthma, emphysema, tuberculosis, pleurisy or other diseases of the lungs n Yes n No 11) Paralysis, epilepsy, MS or other neuromuscular disorder n Yes n No 12) Bleeding or blood disorders except HIV n Yes n No (continued) CA89632 (2/12) Health Net of California, Inc..
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