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Medical History Questionnaire- Version 2

1. Family History
Indicate if any of your immediate family (parents, brothers, sisters, grandparents) have experienced any of the following, the age at which diagnosis occurred and the person's relationship to you.
Are you presently experiencing, or have you ever been treated by a doctor for any of the following?
23. Medication
25. Alcohol Consumption
26. Tobacco: How often do you use tobacco?
X