Medical History (For Learners) No Yes 1. Do you have any allergies? If Yes, please identify below: Medicines Pollens Food Stinging Insects Others: No Yes 2. Do you have any ongoing medical condition? If Yes, please identify below: Asthma Seizure Heart Problem Anemia Bleeding disorder Others: No Yes 3. Have you ever had surgery/hospitalization? If Yes, please identify below: 4. Does anyone in your family have the following conditions: Tuberculosis Cancer If Yes, what kind? Stroke