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["本人患病经历和有关情况说明"]
["病  名","有/无","治愈时间","病  名","有/无","治愈时间","备  注"]
["心脏病","□ 有  □ 无",null,"精神病","□ 有  □ 无"]
["高血压病","□ 有  □ 无",null,"神经官能症","□ 有  □ 无"]
["血液系统疾病","□ 有  □ 无",null,"夜游症","□ 有  □ 无"]
["结核病","□ 有  □ 无",null,"精神活性物质\n滥用和依赖史","□ 有  □ 无"]
["肺气肿","□ 有  □ 无",null,"吸毒史","□ 有  □ 无"]
["支气管扩张","□ 有  □ 无",null,"结缔组织病","□ 有  □ 无"]
["支气管哮喘","□ 有  □ 无",null,"血吸虫病","□ 有  □ 无"]
["胰腺疾病","□ 有  □ 无",null,"血丝虫病","□ 有  □ 无"]
["严重消化\n系统疾病","□ 有  □ 无",null,"颅脑畸形\n颅脑损伤","□ 有  □ 无"]
["急慢性肝炎","□ 有  □ 无",null,"慢性骨髓炎","□ 有  □ 无"]
["肝硬化","□ 有  □ 无",null,"胆结石","□ 有  □ 无"]
["恶性肿瘤","□ 有  □ 无",null,"泌尿系统结石","□ 有  □ 无"]
["急慢性肾炎","□ 有  □ 无",null,"性  病","□ 有  □ 无"]
["肾功能异常","□ 有  □ 无",null,"艾滋病","□ 有  □ 无"]
["糖尿病","□ 有  □ 无",null,"手术史","□ 有  □ 无"]
["甲  亢","□ 有  □ 无",null,"严重外伤史","□ 有  □ 无"]
["内分泌系统病","□ 有  □ 无",null,"文  身","□ 有  □ 无"]
["癫  痫","□ 有  □ 无",null,"其  他","□ 有  □ 无"]
["考生承诺"]
[null,"  本人承诺，以上信息均真实、准确。如有不实，愿承担一切后果。"]
[{"$nulls":4},"考生（签名）："]
[{"$nulls":5},"年      月      日"]

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