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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 8 / 14

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Past

PAST MEDICAL HISTORY Present

Past

Present

EYES/EARS/NOSE/THROAT Blindness Double Vision Cataracts Injury to Eye Glaucoma Iritis Keratitis Optic Neuritis Ringing in Ears Deafness Chronic Ear Infection Sinusitis Difficulty Swallowing Cancer

CARDIOVASCULAR Hypertension Hypotension Myocardial Infarction Heart Attack Angina/Chest Pain Congestive Heart Failure Rapid Heart Rate (Tachycardia) Slow Heart Rate (Bradycardia) Irregular Heart Rate (Arrhythmia) Heart Murmur Mitral Valve Prolapse Rheumatic Heart Disease High Cholesterol/Lipids Vascular Disease (Legs-Arms)

RESPIRATORY Asthma Chronic Bronchitis Tuberculosis Cancer Pneumonia

DERMATOLOGY/HEMATOLOGY

Anemia

Leukemia

Lymphoma

Bleeding Disorder

Psoriasis

Skin Cancer

HIV Positive

AIDS

MUSCULOSKELETAL

Chronic Low Back Pain

Chronic Neck Pain

Muscle Disease

Lupus

Gout

Rheumatoid Arthritis

Osteoarthritis

Fibromyalgia

Connective Tissue Disease

GASTROINTESTINAL

Ulcer

Esophagitis

Jaundice

Hepatitis

Gallstones

Gallbladder Inflammation

Pancreatitis

Crohn's Disease

Ulcerative Colitis

Diverticulosis

GERD

Acid Reflux

Cancer

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 6 of 11

ENDOCRINE

Diabetes

Hyperthyroidism

Hypothyroidism

Cushing's Disease

Addison's Disease

Cancer

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