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other: medications: (name of medication and reason) none _____________________________________________ surgeries/hospitalizations (since last hazmat exam): none do you have any of the following currently or since the last hazmat exam: lung, pulmonary asthma, wheeze abnormal shortness of breath with
bladder, prostate bladder disease/problems kidney disease/problems prostate problems (infection, enlargement, cancer) blood in urine neurologic, special senses (ears, eyes, smell, etc) seizures, fainting, stroke epilepsy (or fits, seizures, convulsions) frequent headaches migraines extreme difficulty with...
https://wellnow.com/app/uploads/2019/11/Hazmat-Questionnaire-1.pdf