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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 10 / 14

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PLEASE LIST ALL PREVIOUS HOSPITALIZATIONS:

Hospital

Date

Doctor

Diagnosis

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

PLEASE LIST ANY OTHER MEDICAL ILLNESS NOT PREVIOUSLY LISTED:

Illness

Past Present

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

PLEASE LIST ALL MEDICATIONS YOU ARE NOW TAKING AND DOSAGE:

1.

8.

__________________________________________

________________________________________________

2.

9.

__________________________________________

________________________________________________

3.

10.

__________________________________________

________________________________________________

4.

11.

__________________________________________

________________________________________________

5.

12.

__________________________________________

________________________________________________

6.

13.

__________________________________________

________________________________________________

7.

14.

__________________________________________

________________________________________________

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 8 of 11

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