| Document Date: 2014-01-03 17:15:14
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Company Visa / / IndustryTerm healthcare team / needle site / insurance / insurance benefits / increase energy / health care services / healthcare needs / healthcare / insurance carrier / food / healthcare staff / energy / / MedicalCondition light-headedness / severe headaches / ALLERGIES / No Yes Type Year Frequent infections / low blood pressure No Yes PLEASE ENCIRCLE ALL ANSWERS No Yes Colitis / frequent cough / No Tetanus / Neuralgia No Yes Bursitis / stomach pain / Smallpox / Yes Yes Yes Yes Yes Yes Yes Fainting / Shortness of breath / Hives / Sciatica / dysfunction / Chronic / No Yes Neuritis / or/disease / Nausea / No Polio / Heart Disease No Yes Arthritis / coughing / bowel disease No Yes Measles No Yes Hemorrhoids / Any itching / back pains / pain / vomiting / persistent cough / rectal disease / fatigue / No High blood pressure / drug poisoning / AIDS / Dizziness / illness / Tiredness / Gonorrhea / Lumbago No Yes Polio / injuries / Chest pain Angina / How many miscarriages / / MedicalTreatment birth control / Antibiotics / vaccination / Acupuncture / SURGERY / / Organization DO YOU NOW HAVE OR HAVE YOU HAD WITHIN THE PAST YEAR / / Person Chris Powell / William Christopher Powell / / Position attorney / PHYSICIAN / / Product Sleeping / Penicillin / ACTH / / Technology cellular telephone / /
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Microsoft Word - General_Information.doc