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Daily health declaration check

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Section 1 Personal and Emergency Contact Information Name Date of birth Address Phone Physician s name Height Weight Person to contact in case of emergency Section 2 General Medical History Please check the following conditions you have experienced. Heart History Heart attack Heart surgery Cardiac catheterization Coronary angioplasty PTCA Cardiac rhythm disturbance Heart valve disease Heart failure Heart transplantation Congenital heart disease Symptoms You experience chest discomfort with exe ...

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