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Adult Patient General Health History Questionnaire
Adult Patient General Health History Questionnaire
Adult Patient General Health History Questionnaire
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  • English (US)
  • 1
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  • 5
    If you have or have had any of the following illnesses and medical problems, then please indicate the year when each started. If you are not certain when an illness started, write down an approximate year. Leave blank for the ones that do not apply.
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  • 6
    If you have or have had any of the following illnesses and medical problems, then please indicate the year when each started. If you are not certain when an illness started, write down an approximate year. Leave blank for the ones that do not apply.
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  • 7
    If you have or have had any of the following illnesses and medical problems, then please indicate the year when each started. If you are not certain when an illness started, write down an approximate year. Leave blank for the ones that do not apply.
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  • 8
    If you have or have had any of the following illnesses and medical problems, then please indicate the year when each started. If you are not certain when an illness started, write down an approximate year. Leave blank for the ones that do not apply.
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  • 9
    Leave blank if it does not apply.
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  • 10
    Leave blank if it does not apply.
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  • 12
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  • 13
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  • 14
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  • 15
    • Yes
    • No
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  • 16
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  • 17
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  • 18
    If any blood relative has suffered any of the following, then please indicate which relative (leave blank if none).
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  • 19
    If any blood relative has suffered any of the following, then please indicate which relative (leave blank if none).
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  • 20
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  • 21
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  • 22
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  • 23
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  • 24
    Please check all that apply.
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  • 25
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  • 31
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