ER Patient Pre-Visit Worksheet Defieftment of Nestle Miry tot It Welt , hew York OS 10011 rei 212.10-1030 fa 212 20-41C legal NOME elk; P. 46J E-PS-re,r4 AARN Date of girth o ' Iteason for Visit: Misdeal History 0 None Do you hats • history of fainting or seizures, 0 NO oyes Surgical His