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Patient Health History Questionnaire 

 

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1. History of Neurologic Problems

* Stroke
* TIA or "Mini Stroke"
* Paralysis
* Seizures
* Alzheimers
* Dementia
* Memory Loss
* Guillian Barre Syndrome
* Brain Tumor
* Parkinson's Disease
* Head Trauma

2. HEENT Problems

* Glaucoma
* Cataracts
* Macular Degeneration
* Blindness
* Deafness
* Throat Problems
* Difficulty Swallowing
* Eye Glasses
* Dentures
* Partials
* Body Piercing

3. History of Heart Problems

* Heart Attack
* Chest Pain
* Rheumatic Fever
* High Blood Pressure
* Congestive Heart Failure
* Blood Clots
* Enlarged Heart
* Born with Heart Problems
* Irregular Heart Beat
* Murmur
* Pacemaker
* Implanted Defibrillator
* Heart Surgery
* Stent
* Valve Replacement
* Echo/Stress Test

4. History of Lung Problems

* Any recent increase in sedation and sleep
* Pneumonia or Bronchitis
* Shortness of Breath
* Asthma
* Reactive Airway
* COPD
* Emphysema
* Tuberculosis
* Tracheostomy
* Cystic Fibrosis
* Blood Clot in the Lung
* Recent Lung Infection
* Sleep Apnea
* C-PAP

5. History of Stomach or Intestinal Problems

* Reflux or GERD
* Hiatal Hernia
* Ulcers
* Hepatitis
* Liver Disease
* Bloody Stools
* Irritable Bowel
* Bowel Obstruction
* Colostomy/Ileostomy