Reading Practice

Read the information Roberto provided on this form and then answer the questions by selecting the correct answer.

Medical History

Today’s Date October 23, 2004

Name Gonzalez Roberto	 Miguel
Address 4124 N Kiowa Colorado Springs, CO 80905
Home Phone 719-234-5567 Work Phone 719-278-8819
Birth date June 16, 1978 Sex Male
Birthplace Tucson, Arizona
Martial Status Single Employer U.S. Postal Service
Insurance Company Health One Policy # 897522-C

Do you have or have you had any of the following?
Damaged heart valve?
___ yes _X__ no
Cardiovascular disease? ___ yes __X_ no
Allergies? _X__ yes ___ no
Sinus Trouble? _X__ yes ___ no
Diabetes? ___ yes _X__ no
Low/high blood pressure? ___ yes __X_ no
Stomach ulcer? ___ yes __X_ no
Kidney trouble? ___ yes __X_ no

List any allergic reactions to drugs: penicillin and aspirin