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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 11 / 14

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PLEASE LIST ALL MEDICATIONS TO WHICH YOU ARE ALLERGIC:

1.

3.

__________________________________________

________________________________________________

2.

4.

__________________________________________

________________________________________________

5.

7.

__________________________________________

________________________________________________

6.

8.

__________________________________________

________________________________________________

1) Marital Status Married Divorced Single Widowed

(3) Cigarette Smoker Yes Past No Present

(3) Daily Caffeine Consumption Never Moderate Occasional Excessive

(2) Alcohol Intake Never Moderate Occasional Excessive

(4) Cigar or Pipe Smoker Yes Past No Present

(4) Education Elementary School College High School Post Graduate School

(5) Cigarette Smoker Yes No

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 9 of 11

SOCIAL HISTORY

  • Psychiatric Illness

  • Suicide

  • Parkinson's Disease

  • Muscle Disease

  • Peripheral Nerve Disease

  • Multiple sclerosis

FAMILY HISTORY

  • Hypertension

  • Coronary Artery Disease

  • Heart Attack

  • Heart Surgery

  • Other Heart Disease

  • High Cholesterol

  • Peripheral Vascular Disease Diabetes

  • Cancer

  • Tuberculosis

  • Asthma

  • Other Lung Disease

  • Ulcer Disease

  • Kidney Disea

  • Stroke

  • Brain Tumor

  • Epilepsy

  • Migraine

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