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NO CHANGE
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Do you have any lung disease?
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If YES, please describe.
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Any heart or vascular disease?
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If YES, please describe.
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Brain or nervous system disease?
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If YES, please describe.
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Skin disease?
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If YES, please describe.
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Diseases of digestion system?
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If YES, please describe.
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Ever had any type of cancer?
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If YES, please describe.
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Any blood disease?
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If YES, please describe.
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Any mental/emotional problems?
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If YES, please describe.
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Diseases of bones or joints?
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If YES, please describe.
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Diabetes or thyroid problems?
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If YES, please describe.
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Other diseases or conditions?
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If YES, please describe.
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Have you had any surgeries?
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If YES, please describe.
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Family history of stroke?
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If YES, please describe.
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Fam hist heart disease?
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If YES, please describe.
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Fam hist high blood pressure?
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If YES, please describe.
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Fam hist lung disease?
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If YES, please describe.
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Fam hist diabetes?
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If YES, please describe.
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Fam hist thyroid disease?
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If YES, please describe.
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Fam hist cancer?
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If YES, please describe.
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Fam hist blood disease?
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If YES, please describe.
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Fam hist other disease?
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If YES, please describe.
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Have you ever been a smoker?
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If yes, when did you start?
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If YES, how much on average?
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Do you currently smoke?
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If NO, when did you quit?
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Do you drink alcohol?
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If YES, how much do you drink?
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How much on weekends?
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How far did you go in school?
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Which best describes you?
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