Past Medical History

Please correct the errors described below.

PAST MEDICAL HISTORY I HISTORIA MEDICA

(If you personally have EVER HAD or CURRENTLY HAVE any of the problems listed below, please circle YES and give details in the comments section. Otherwise, please circle NO)

(Por favor conteste todas las preguntas que siguen. Si su respuesta es "SI”, de una explicacion abajo)

HEALTH CONDITION

15. ALCOHOL USE I USO DE ALCOHOL

16. ILLICIT DRUG USE / USO DE DROGAS

Pregnancy History

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