DTS Confidential Health Form
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  • 19. Have you ever had or do you have any of the following?

    If yes, please describe at the end of the section
  • 20. Have you ever had any of the following communicable diseases?

  • 21. Immunization Record

    (State the month and year of any immunizations you have)
  • 22. Have any of your relatives ever had any of the following?

    (If yes, please list what relation they are to you)