PERSONNAL MEDICAL HISTORY

SPLEEP DISORDER

APPETITE DISORDER

SEXUAL DISORDER

BEHAVIOUR TROUBLE

PERIPHERAL NEUROPATHIES

ALCOHOLISM

SMOKING

TUBERCULOSIS

MENINGITIS

STROKE

EPILEPSY

OTITIS

TOOTH DECAY

RHEUMATISM

PARALYSIS

HIGH BLOOD PRESSION

SUICIDAL IDEATION

NERVOUSNESS

DATE OF LAST PERIOD

HYPOTENSION