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Personal details


Emergency contact


General


Past medical history

If you know your vaccination history before entering Iran, Declare it:
Do you now or have you ever had:

Current medications


Systems Review

In the past month, have you had any of the following problems? (If the answer is Yes mark in the box and explain)
GENERAL
NERVOUS SYSTEM
PSYCHIATRIC
Muscle/Joints/Bones
EARS
EYES
THROAT
HEART AND LUNGS
SKIN
STOMACH AND INTESTINES
BLOOD
KIDNEY/URINE/BLADDER