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PATIENT S OCCUPATION e. WEIGHT 9. ARE YOU Check one RIGHT HANDED LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON T KNOW Household contact with anyone with tuberculosis Shortness of breath Chronic cough Loss of finger or toe Tuberculosis or positive TB test Bone joint or other deformity Pain or pressure in chest Painful or trick shoulder or elbow Blood in sputum or when coughing Palpitation or pounding heart Heart trouble E.

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