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PATIENT INSTRUCTIONS FOR COMPLETING THE PATIENT HEALTH/HISTORY QUESTIONNAIRE: - page 9 / 14

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Menstrual Problems

Myopathy

Hormone Therapy

Other Muscular Disorder

Birth Control Pills

Nerve Injury

Menopause

Neuropathy

Breast Cancer

Multiple Sclerosis

Other Cancer

Meningitis

Endometriosis

Encephalitis

Pyelonephritis

Alzheimer's Disease

Kidney Stones

Stroke

Urinary Tract Stones

Brain Hemorrhage

Recurrent Infection

Transient Ischemic Attack

Urinary Retention

Paralysis

Cancer

Brain Tumor

PSYCHOLOGICAL Depression Panic Attacks Anxiety Intellectual Loss Memory Loss Bipolar Disorder

BAYLOR UNIVERSITY MEDICAL CENTER DALLAS, TEXAS

52334 (Rev. 03/10)

PATIENT HEALTH/HISTORY QUESTIONNAIRE Page 7 of 11

GENITOURINARY

Arnold-Chiari Malformation Head Trauma/Injury Headaches Migraines

PAST MEDICAL HISTORY (Continued)

Past

Present

Spinal Cord Tumor Seizure

  • Epilepsy

  • Syncope/Fainting

  • Parkinson's Disease

Tremor Spinal Cord Disorder

MEN ONLY

Prostate Problems

Impotence

Cancer

Past

Present

NEUROLOGICAL

WOMEN ONLY

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