461 lines
40 KiB
Plaintext
461 lines
40 KiB
Plaintext
Category,Question,Base Question (Reference),Sub Question (Reference),SubQuestion,type,options
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"Medical History, Family history",High blood pressure,,,,radio,"yes,no"
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"Medical History, Family history",Heart attack,,,,radio,"yes,no"
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"Medical History, Family history",High cholesterol,,,,radio,"yes,no"
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"Medical History, Family history",Stroke/TIA,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Atrial Fib/Arrhythmia ,,,,radio,"yes,no"
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"Medical History, Family history",PFO/ Hole in Heart,,,,radio,"yes,no"
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"Medical History, Family history",Cancer,,,,radio,"yes,no"
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"Medical History, Family history",Coagulopathy/Clotting disorder,,,,radio,"yes,no"
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"Medical History, Family history",Diabetes ,,,,radio,"yes,no"
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"Medical History, Family history",Kidney disease ,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Thyroid disease,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Do you drink alcohol?,,,,radio,"yes,no"
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"Medical History, Family history",Current everyday,,,,radio,"yes,no"
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"Medical History, Family history",Current someday,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
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"Medical History, Family history",Beer/Wine/Liquor How many per week?,,,,text,
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"Medical History, Family history",Do you use recreational Drugs?,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
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"Medical History, Family history,Neurology",Have you ever used tobacco?,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
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"Medical History, Family history",How many packs per day do you or did you smoke?,,,,radio,"< ½, ½ ,1,1 ½,2,2 1/2,3"
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"Medical History, Family history",Smoking,,,,radio,"yes,no"
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"Medical History, Family history",Angina,,,,radio,"yes,no"
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"Medical History, Family history",Stent placement,,,,radio,"yes,no"
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"Medical History, Family history",Bypass surgery,,,,radio,"yes,no"
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"Medical History, Family history",Pacemaker implant,,,,radio,"yes,no"
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"Medical History, Family history",Stroke,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Mini-stroke (TIA),,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Carotid surgery,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Aortic aneurysm,,,,radio,"yes,no"
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"Medical History, Family history",Fast heart rate,,,,radio,"yes,no"
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"Medical History, Family history",Sudden death,,,,radio,"yes,no"
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"Medical History, Family history",Pulmonary embolism,,,,radio,"yes,no"
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"Medical History, Family history",COPD (lung disease),,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Osteoporosis,,,,radio,"yes,no"
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"Medical History, Family history",Mental illness,,,,radio,"yes,no"
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"Medical History, Family history",Congestive heart failure,,,,radio,"yes,no"
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"Medical History, Family history",Coronary artery disease,,,,radio,"yes,no"
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"Medical History, Family history,Neurology,Urology",Depression,,,,radio,"yes,no"
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"Medical History, Family history",Diverticulitis,,,,radio,"yes,no"
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"Medical History, Family history",GERD (heartburn),,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Glaucoma,,,,radio,"yes,no"
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"Medical History, Family history",Headaches,,,,radio,"yes,no"
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"Medical History, Family history",Heart murmur,,,,radio,"yes,no"
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"Medical History, Family history,Neurology,Urology",HIV/AIDS,,,,radio,"yes,no"
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"Medical History, Family history",Hyperlipidemia (high cholesterol),,,,radio,"yes,no"
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"Medical History, Family history",Hypertension (high blood pressure),,,,radio,"yes,no"
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"Medical History, Family history",Hypothyroidism,,,,radio,"yes,no"
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"Medical History, Family history",Irregular menses,,,,radio,"yes,no"
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"Medical History, Family history",Kidney disease,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Liver disease,,,,radio,"yes,no"
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"Medical History, Family history",Menorrhagia,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Myocardial infarction (heart attack),,,,radio,"yes,no"
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"Medical History, Family history",Nerve/muscle disease,,,,radio,"yes,no"
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"Medical History, Family history",Osteoporosis,,,,radio,"yes,no"
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"Medical History, Family history,Urology",Seizures,,,,radio,"yes,no"
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"Medical History, Family history",Sickle cell anemia,,,,radio,"yes,no"
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"Medical History, Family history",Sleep apnea,,,,radio,"yes,no"
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"Medical History, Family history",Substance abuse,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Tuberculosis,,,,radio,"yes,no"
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"Medical History, Family history",Ulcers,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Appendectomy,,,,radio,"yes,no"
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"Medical History, Family history",Bariatric surgery,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Brain surgery,,,,radio,"yes,no"
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"Medical History, Family history",Breast surgery,,,,radio,"yes,no"
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"Medical History, Family history",CABG (bypass),,,,radio,"yes,no"
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"Medical History, Family history",Cesarean section,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Cholecystectomy (gall bladder removal),,,,radio,"yes,no"
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"Medical History, Family history",Colon surgery,,,,radio,"yes,no"
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"Medical History, Family history",Cosmetic surgery,,,,radio,"yes,no"
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"Medical History, Family history",Eye surgery,,,,radio,"yes,no"
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"Medical History, Family history",Fracture surgery,,,,radio,"yes,no"
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"Medical History, Family history",Hernia repair,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Hysterectomy (ovaries removed),,,,radio,"yes,no"
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"Medical History, Family history",Hysterectomy (ovaries remain),,,,radio,"yes,no"
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"Medical History, Family history",Joint replacement,,,,radio,"yes,no"
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"Medical History, Family history",Prostate surgery,,,,radio,"yes,no"
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"Medical History, Family history",Small intestine surgery,,,,radio,"yes,no"
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"Medical History, Family history",Spine surgery,,,,radio,"yes,no"
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"Medical History, Family history",Tubal ligation (tubes tied),,,,radio,"yes,no"
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"Medical History, Family history",Valve replacement,,,,radio,"yes,no"
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"Medical History, Family history,Neurology",Peripheral Neuropathy,,,,checkbox,
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"Medical History, Family history",Vasectomy,,,,radio,"yes,no"
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"Medical History,Urology",Do you ever drink alcohol?,,,,radio,"Yes – if yes, complete all alcohol related questions,No – if no, skip to next section"
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Medical History,,,,Please indicate the quantity per week of each,radio,"yes,no"
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Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Glasses of wine,text,
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Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Can/bottles of beer,text,
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Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Shots of liquor,text,
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Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Drinks containing .5 oz of alcohol,text,
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Medical History,Have people ever felt like you should cut down on drinking?,,,,radio,"yes,no"
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Medical History,Have people annoyed you by criticizing your drinking?,,,,radio,"yes,no"
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Medical History,Have you ever felt guilty about your drinking?,,,,radio,"yes,no"
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Medical History,"Have you ever had an ""eye-opener"" (an alcoholic drink first thing in the morning) to help you feel better?",,,,radio,"yes,no"
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Medical History,Drugs and tobacco,,,Do you use drugs?,radio,"yes,no"
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Medical History,,,,"If you use drugs, how many times per week?",text,
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Medical History,,,,What type(s) of drugs do you use? ,text,
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Medical History,Check one of the following about smoking tobacco,,,,radio,"Never smoked,Exposed to second hand smoke,Former smoker,Smoke some days,Smoke everyday"
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Medical History,"If you smoked or used to smoke, how many packs do or did you smoke per day?",,,,text,
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Medical History,How many years did you smoke / have you smoked?,,,,text,
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Medical History,"If you quit smoking, when did you quit?",,,,text,
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"Medical History,Neurology",Check one of the following about smokeless tobacco,,,,radio,"Never usedm,Former user,Current user"
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Medical History,"If you quit smokeless tobacco, when did you quit?",,,,text,
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Medical History,Are you ready to quit smoking or using smokeless tobacco?,,,,text,
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Medical History,Do you use e-cigarettes?,,,,radio,"No,Used in the past,Not presently,Occasionally,Daily"
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"Medical History,Urology",Sexual activity,,,,,
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Medical History,,Sexual activity,,Are you sexually active?,radio,"Yes,No,Not currently"
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"Medical History,Urology",,Sexual activity,Are you sexually active?,"If yes, are your partner(s):",radio,"Male,Female,Both"
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"Medical History,Urology",Type of birth control / protection (check all that you use):,,,,checkbox,"Not having sex (abstinence),Condom,Injection,IUD (intrauterine device),Oral contraceptives (Pill),Partner vasectomy,Patch,Post-Menopausal,Vasectomy,None,Other (specify):"
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Medical History,Do you have a new sexual partner?,,,,text,
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"Medical History,Oncology","On average, how many minutes do you engage in exercise at this level?",,,,radio,"0 min,10 min,20 min,30 min,40 min,50 min,60 min,70 min,80 min,90 min,100 min,110 min,120 min,130 min,140 min,150+ min"
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"Medical History,Oncology","On average, how many days per week do you engage in moderate to strenuous exercise?",,,,radio,"1 day,2 days,3 days,4 days,5 days,6 days,7 days"
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Medical History,,,,,radio,"yes,no"
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"Medical History,Neurology",Tonsillectomy and Adenoidectomy,,,,radio,"yes,no"
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Medical History,Marital status,,,,radio,"Divorced,Legally separated,Married,Significant other
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Single,Widow,Unknown"
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"Medical History, Family history",Leg-vascular surgery,,,,radio,"yes,no"
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Medical History,Doctor Intake Request,,,,radio,"yes,no"
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Medical History,,Doctor Intake Request,,What aspects of hormone replacement therapy (HRT) intrigue you?,text,
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Medical History,,Doctor Intake Request,,Is your objective with the program to achieve weight loss?,radio,"yes,no"
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Medical History,,Doctor Intake Request,,What is your assigned sex at birth?,,"male,female"
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Medical History,,Doctor Intake Request,,"Have you undergone a comprehensive physical examination by a medical professional within the past three years, which included assessments of vital signs such as weight, blood pressure, and heart rate?",radio,"yes,no"
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Medical History,,Doctor Intake Request,,"Did you experience any medical issues? If so, could you please elaborate?",radio,"yes,no"
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Medical History,,Doctor Intake Request,,Have you ever received a diagnosis of prostate cancer?,radio,"yes,no"
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Medical History,,Doctor Intake Request,,Have you been prescribed any hormone treatments currently or in the past?,radio,"Thyroid Medication,Testosterone Treatment,Estrogen Blocker,HGH,Ipamoreline,Colomipheine,HCG,Other,None"
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Medical History,,Doctor Intake Request,,"Are you currently using or have you used any over-the-counter or prescription medications, excluding hormone treatments? (Please note that your responses will be cross-checked against prescription and insurance records. Failure to disclose current prescriptions and/or medical conditions may result in disapproval for your safety.)",radio,"yes,no"
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Medical History,,Doctor Intake Request,,Do you have any allergies to medications?,radio,"yes,no"
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Medical History,,Doctor Intake Request,,Do you intend to have children at some point in the future?,radio,"yes,no"
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Medical History,,Doctor Intake Request,,Is your partner currently pregnant or breastfeeding?,radio,"yes,no,Not Applicable"
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"Medical History,Neurology",,Doctor Intake Request,,Does your family have a history of any of the following disorders?,radio,"Drug Alcohol,Cancer,Heart Disease,Thyroid Disease,Low Testosterone,None"
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Medical History,,Doctor Intake Request,,Are you currently experiencing any erectile dysfunction (ED) issues?,radio,"Never,Almost Never,Occasionally,Almost Always,Always"
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Medical History,,Doctor Intake Request,,"Have you ever been diagnosed with thyroid disorders such as hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), Hashimoto's Disease, or Graves' Disease?",radio,"yes,no"
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Medical History,How many years did you or have you smoked?,,,,radio,
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"Medical History, Family history",Heart Disease,,,,text,
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"Medical History, Family history,Neurology",Bleeding Disorder,,,,text,
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"Medical History, Family history,Neurology",High Blood Pressure,,,,text,
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"Medical History, Family history,Neurology",Blood Clots,,,,text,
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"Medical History, Family history",High Cholesterol,,,,text,
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"Medical History, Family history,Neurology",Cancer type and stroke,,,,text,
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"Medical History, Family history,Neurology",Diabetes ,,,,text,
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Medical History,Do you have any known Allergies to Medications?,,,,checkbox,
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Medical History,,Do you have any known Allergies to Medications?,,,checkbox,
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Medical History,,Do you have any known Allergies to Medications?,,Iodine,radio,"yes,no"
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Medical History,,Do you have any known Allergies to Medications?,,Latex?,radio,"yes,no"
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Medical History,,Do you have any known Allergies to Medications?,"Latex?,Iodine?",Reaction,text,
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Medical History,,Do you have any known Allergies to Medications?,,Others?,radio,"yes,no"
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Medical History,,,Others?,Please list Medication and Reaction,text,
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Medical History,What is your current weight,,,,text,
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Medical History,What is your current height,,,,radio,"yes,no"
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Medical History,,What is your current height,,Feet,text,
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Medical History,,What is your current height,,inches,text,
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Medical History,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,,,checkbox,
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Medical History,,,,Plavix/Clopidogrel:,radio,"yes,no"
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Plavix/Clopidogrel:,Dose/Frequency,text,
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Plavix/Clopidogrel:,Reason,text,
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Coumadin/Warfarin:,radio,"yes,no"
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Coumadin/Warfarin:,Dose/Frequency,text,
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Coumadin/Warfarin:,Reason,text,
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Aspirin,radio,"yes,no"
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Aspirin,Dose/Frequency,text,
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Aspirin,Reason,text,
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Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Please list the Provider that is monitoring any of the above medications:,text,
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Medical History,Review of Systems,,,,radio,"yes,no"
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Medical History,,Review of Systems,,Constitutional,radio,"yes,no"
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"Medical History,Oncology,Neurology",,Review of Systems,Constitutional,Fatigue/Drenching Night Sweats,checkbox,
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"Medical History,Neurology",,Review of Systems,Constitutional,Fever/Chills,checkbox,
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Medical History,,Review of Systems,Constitutional,General health excellent/Poor,checkbox,
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"Medical History,Oncology",,Review of Systems,Constitutional,Unexplained weight loss/Gain,checkbox,
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Medical History,,Review of Systems,,Respiratory,radio,"yes,no"
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"Medical History,Neurology",,Review of Systems,Respiratory,Asthma/ Anesthetic problems,checkbox,
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"Medical History,Neurology",,Review of Systems,Respiratory,COPD/Pneumonia/Emphysema,checkbox,
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"Medical History,Oncology",,Review of Systems,Respiratory,Coughing/coughing up blood,checkbox,
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"Medical History,Neurology",,Review of Systems,Respiratory,Hoarsness/Obstructive Sleep Apnea,checkbox,
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Medical History,,Review of Systems,Respiratory,"Oxygen Dependent LPM ",checkbox,
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"Medical History,Oncology",,Review of Systems,Respiratory,Shortness of Breath with Exertion,checkbox,
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"Medical History,Neurology",,Review of Systems,Respiratory,Shortness of breath /Wheezing,checkbox,
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Medical History,,Review of Systems,Respiratory,Tuberculosis or exposure,checkbox,
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Medical History,,Review of Systems,,Neurological,radio,"yes,no"
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"Medical History,Neurology",,Review of Systems,Neurological,Migraines/Headache/Vertigo,checkbox,
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Medical History,,Review of Systems,Neurological,Temporary/Paralysis Arm/Leg/Face,checkbox,
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"Medical History,Oncology,Neurology",,Review of Systems,Neurological,Tingling/Numbness,checkbox,
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"Medical History,Oncology,Neurology",,Review of Systems,Neurological,Speech difficulties/Seizures,checkbox,
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Medical History,,Review of Systems,,Eyes,radio,"yes,no"
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"Medical History,Oncology",,Review of Systems,Eyes,Blurry vision/Double vision,checkbox,
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Medical History,,Review of Systems,Eyes,Cataracts/ Macular degeneration,checkbox,
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Medical History,,Review of Systems,Eyes,Glasses/Contacts/Blindness,checkbox,
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Medical History,,Review of Systems,Eyes,Glaucoma/Retinopathy,checkbox,
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Medical History,,Review of Systems,Eyes,Partial loss of vision/blind spots,checkbox,
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"Medical History,Urology",,Review of Systems,,Gastrointestinal,radio,"yes,no"
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"Medical History,Oncology",,Review of Systems,Gastrointestinal,Abdominal pain/Blood in stool,checkbox,
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Medical History,,Review of Systems,Gastrointestinal,Black or Tarry stool,checkbox,
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"Medical History,Oncology",,Review of Systems,Gastrointestinal,Bloating/Diarrhea/Constipation,checkbox,
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"Medical History,Oncology",,Review of Systems,Gastrointestinal,Loss of appetite/Heartburn,checkbox,
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"Medical History,Oncology",,Review of Systems,Gastrointestinal,Nausea/Vomiting,checkbox,
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Medical History,,Review of Systems,Gastrointestinal,Ulcer disease/Pain after eating,checkbox,
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Medical History,,Review of Systems,Gastrointestinal,Vomited blood,checkbox,
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Medical History,,Review of Systems,,Endocrine,radio,"yes,no"
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"Medical History,Urology",,Review of Systems,Endocrine,Cold/Heat intolerance,checkbox,
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"Medical History,Urology",,Review of Systems,Endocrine,History of drug resistant infection,checkbox,
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Medical History,,Review of Systems,,Ears/Nose/Mouth/Throat,radio,"yes,no"
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Medical History,,Review of Systems,Ears/Nose/Mouth/Throat,Dentures/Difficulty swallowing,checkbox,
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"Medical History,Oncology,Neurology",,Review of Systems,Ears/Nose/Mouth/Throat,Hearing Loss/ringing in ears,checkbox,
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"Medical History,Neurology",,Review of Systems,Ears/Nose/Mouth/Throat,Prolonged Nose bleeds,checkbox,
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Medical History,,Review of Systems,Ears/Nose/Mouth/Throat,Voice change,checkbox,
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Medical History,,Review of Systems,,Psychiatric,radio,"yes,no"
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"Medical History,Neurology",,Review of Systems,Psychiatric,Anxiety/Depression,checkbox,
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Medical History,,Review of Systems,Psychiatric,Confusion/Memory loss,checkbox,
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Medical History,,Review of Systems,Psychiatric,Difficulty sleeping,checkbox,
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Medical History,,Review of Systems,,Cardiovascular,radio,"yes,no"
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Medical History,,Review of Systems,Cardiovascular,Ankle Swelling /Varicosities,checkbox,
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Medical History,,Review of Systems,Cardiovascular,Calf pain with/without exercise,checkbox,
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"Medical History,Oncology",,Review of Systems,Cardiovascular,Chest pain with exertion/Exercise,checkbox,
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Medical History,,Review of Systems,Cardiovascular,Chest pain/ Heart murmur,checkbox,
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Medical History,,Review of Systems,Cardiovascular,Dyspnea on exertion/Syncope,checkbox,
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Medical History,,Review of Systems,Cardiovascular,Irregular/Rapid heart rate,checkbox,
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Medical History,,Review of Systems,Cardiovascular,Leg Pain/Cramping in legs at night,checkbox,
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"Medical History,Oncology",,Review of Systems,,Genitourinary,checkbox,
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Medical History,,Review of Systems,,Impotence,checkbox,
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Medical History,,Review of Systems,Impotence,Incontinence /Difficulty Voiding,checkbox,
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"Medical History,Neurology",,Review of Systems,Impotence,Kidney stones,checkbox,
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Medical History,,Review of Systems,Impotence,Suprapubic/Indwelling Catheter,checkbox,
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"Medical History,Neurology,Urology",,Review of Systems,Impotence,Urgency/Blood in Urine,checkbox,
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Medical History,,Review of Systems,,Integumentary (Skin),radio,"yes,no"
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Medical History,,Review of Systems,,New skin lesions/Skin Cancer,checkbox,
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"Medical History,Oncology,Neurology",,Review of Systems,,Rash/Persistent itching,checkbox,
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Medical History,,Review of Systems,,Unhealed/Delayed healing of sores,checkbox,
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Medical History,,Review of Systems,,Heme/Lymphatic/Immune,radio,"yes,no"
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Medical History,,Review of Systems,Heme/Lymphatic/Immune,Anemia/Low platelet count,checkbox,
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"Medical History,Neurology",,Review of Systems,Heme/Lymphatic/Immune,Bleeding disorder/Easy bleeding,checkbox,
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Medical History,,Review of Systems,Heme/Lymphatic/Immune,Easy bruising,checkbox,
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Medical History,,Review of Systems,Heme/Lymphatic/Immune,Lymphoma/Leukemia,checkbox,
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Medical History,,Review of Systems,Heme/Lymphatic/Immune,Frequent illnesses,checkbox,
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ALLERGY/ASTHMA ,COUGH OR WHEEZE SYMPTOMS,,,,radio,"yes,no"
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,DAYTIME SYMPTOMS,radio,"yes,no"
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,less than twice weekly,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,more than twice weekly,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,daily,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,"DAYTIME SYMPTOMS,NIGHT SYMPTOMS",continuous,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,NIGHT SYMPTOMS,radio,"yes,no"
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,less than twice monthly,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,more than twice monthly,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,nightly,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,DURING OR AFTER EXERCISE,radio,"yes,no"
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,exercise symptoms may occur,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,less than once weekly,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,frequent exercise symptoms,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,significant limitation activity,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,EXTRA ALBUTEROL USE,radio,"yes,no"
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,occasional use,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,periods of daily use,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,daily use,checkbox,
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ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,frequent daily need,checkbox,
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||
ALLERGY/ASTHMA ,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,,,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,TRIGGERS OF COUGH OR WHEEZE:,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,colds/infection,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,morning,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,night,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,exercise,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,cold air,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,outdoors,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,paint fumes,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,changes in humidity,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,school/work environment,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,"allergies ",checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,stress,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,second hand smoke,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,tobacco use,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,perfume/aerosol sprays,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,"mile run time ",checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,pneumonia/bronchitis,checkbox,
|
||
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,MONTHS OF SYMPTOMS:,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",January,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 11 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",February,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 12 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",March,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 13 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",April,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 14 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",May,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 15 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",June,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 16 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",July,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 17 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",August,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 18 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",September,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 19 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",October,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 20 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",November,checkbox,
|
||
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 21 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",December,checkbox,
|
||
ALLERGY/ASTHMA ,ALLERGY - LIKE SYMPTOMS,,,,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,,,UPPER RESPIRATORY SYMPTOMS,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sneezing,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sniffing/drippy nose,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,itchy eyes/nose,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,dark circles under eyes,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sinus infection,checkbox,
|
||
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,mouth breathing/snoring,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,congestion,checkbox,
|
||
"ALLERGY/ASTHMA, Oncology, Neurology",,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,headaches,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,,OTHER,text,
|
||
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,OTHER,eczema,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,hives,checkbox,
|
||
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,OTHER,dry skin,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,itchy skin,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,ear infection,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,nausea,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,dry cough,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,throat clearing,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,,EXPOSURES,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,Smoke,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,fireplace/woodstove,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,animals,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,"feather (pillows, stuffed animals)",checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,carpeting,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,bedroom carpeting,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,forced air heat,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,mold in lower level,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,humidifier/vaporizer,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,bedroom in lower level,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,rural,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,city,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,suburbs,checkbox,
|
||
"ALLERGY/ASTHMA , Urology",,ALLERGY - LIKE SYMPTOMS,,ENVIRONMENTAL CONTROLS,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,air conditioning,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,HEPA filter,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,dehumidifier,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,wood floors,checkbox,
|
||
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,mattress & pillow covers,checkbox,
|
||
ALLERGY/ASTHMA ,TESTING/EVALUATION/EDUCATION:,TESTING/EVALUATION/EDUCATION:,,Has the patient ever had a breathing/lung function test?,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,Has the patient ever had a breathing/lung function test?,"If yes, when?",text,"yes,no"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have an action plan at school/daycare?,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,Please check those items which trigger your child’s allergy or asthma symptoms,,,,checkbox,"Dust,Cold Air,Exercise,Viral Infection,Ear or Sinus Infections,Weather Changes,Pollens,Cigarette Smoke,Strong odors,Cats,Dogs"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,, Has the patient ever had allergy testing?,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Has the patient had their flu vaccine this year?,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Has the patient ever had flu vaccine?,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have an action plan at home? ,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have any questions about your action plan?,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Have you received asthma information?,radio,"yes,no"
|
||
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Would you like more information? ,radio,"classes,reading material,websites"
|
||
Cardiology,Personal History,,,,radio,"yes,no"
|
||
"Cardiology,Oncology,Neurology",,Personal History,,Dizziness or fainting,radio,"Within last 30 days,In the past"
|
||
"Cardiology,Neurology",,Personal History,,Falls that caused an injury,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Stroke,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Shortness of breath when walking 1 to 2 blocks,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Shortness of breath when climbing 1 flight of stairs,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Shortness of breath when lying down,radio,"Within last 30 days,In the past"
|
||
"Cardiology,Neurology,Urology",,Personal History,,Lower leg cramps while walking,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Bleeding problems or low iron (also called anemia),radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Blood clot in leg (also called phlebitis),radio,"Within last 30 days,In the past"
|
||
"Cardiology,Neurology",,Personal History,,High cholesterol,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Diabetes,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,High blood pressure,radio,"Within last 30 days,In the past"
|
||
"Cardiology,Neurology",,Personal History,,Heart murmur or abnormal heart valve,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Uncomfortable feeling in the chest,radio,"Within last 30 days,In the past"
|
||
"Cardiology,Neurology",,Personal History,,Chest pain with activity (also called angina),radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Heart attack (also called myocardial infarction),radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,Swollen legs,radio,"Within last 30 days,In the past"
|
||
Cardiology,,Personal History,,ankles or feet,radio,"Within last 30 days,In the past"
|
||
"Cardiology,Oncology",,Personal History,,Irregular heartbeat,radio,"Within last 30 days,In the past"
|
||
Cardiology,Have you had any of the following tests or procedures,,,,radio,"yes,no"
|
||
Cardiology,,Have you had any of the following tests or procedures,,Stress test or treadmill test:,radio,
|
||
Cardiology,,Have you had any of the following tests or procedures,,Cardiac catheterization or angiogram:,radio,
|
||
Cardiology,,Have you had any of the following tests or procedures,,Angioplasty or stent,radio,
|
||
"Cardiology,Neurology",,Have you had any of the following tests or procedures,,"Heart surgery If so, what kind?",radio,"yes,no"
|
||
Cardiology,,Have you had any of the following tests or procedures,"Heart surgery If so, what kind?",please explain,text,
|
||
Cardiology,"Do you follow a special meal plan or diet (such as Atkins®, Weight Watchers®, vegetarian, low fat, or diabetic)?",,,,radio,"yes,no"
|
||
Cardiology,,"Do you follow a special meal plan or diet (such as Atkins®, Weight Watchers®, vegetarian, low fat, or diabetic)?",,"If YES, which meal plan or diet do you follow?",text,
|
||
Cardiology,Do you exercise regularly?,,,,radio,"yes,no"
|
||
Cardiology,,Do you exercise regularly?,,"If YES, how many days a week?",text,
|
||
"Oncology,Neruology",Fever over 100 degrees F,,,,checkbox,
|
||
"Oncology,Neurology",Bone pain,,,,checkbox,
|
||
"Oncology,Neruology",Joint pain or stiffness,,,,checkbox,
|
||
Oncology,Lumps under the skin,,,,checkbox,
|
||
Oncology,New spots,,,,checkbox,
|
||
Oncology,Sores that won’t heal,,,,checkbox,
|
||
Oncology,Yellowing of eyes or skin (jaundice),,,,checkbox,
|
||
Oncology,Serious cough that brings up a lot of mucus or phlegm,,,,checkbox,
|
||
"Oncology,Neruology","Weakness in hand, arm, or leg",,,,checkbox,
|
||
Oncology,Problems with balance,,,,checkbox,
|
||
Oncology,Dry mouth,,,,checkbox,
|
||
Oncology,Problems chewing,,,,checkbox,
|
||
Oncology,Problems swallowing,,,,checkbox,
|
||
Oncology,Problems remembering things,,,,checkbox,
|
||
Oncology,Hard time finding the right word,,,,checkbox,
|
||
Oncology,Hard time concentrating,,,,checkbox,
|
||
"Oncology,Neruology",Double vision,,,,checkbox,
|
||
Oncology,Sudden need to urinate,,,,checkbox,
|
||
"Oncology,urology",Leaking urine,,,,checkbox,
|
||
Oncology,Are you having pain now?,,,,radio,"yes,no"
|
||
Oncology,,Are you having pain now?,,"If YES, where is your pain?",text,
|
||
Oncology,,,,How often are you in pain?,text,
|
||
Oncology,,,,When did your pain start?,text,
|
||
Oncology,"How would you describe your pain on a scale from 0 to 10, with 0 being no pain and 10 being worst pain ever?",,,,radio,"0 ,1, 2, 3, 4, 5, 6, 7, 8, 9,10"
|
||
Oncology,Are you controlling your pain with medicine?,,,,radio,"yes,no"
|
||
Oncology,,Are you controlling your pain with medicine?,,"If YES, what pain medicine do you take?",text,
|
||
Oncology,,,,How often do you take this pain medicine?,text,
|
||
Oncology,"Do you live in an Assisted Living Facility, Adult Family Home, Nursing Home?",,,,radio,"yes,no"
|
||
Oncology,May we give information about your health to another person?,,,,radio,"yes,no"
|
||
Oncology,,May we give information about your health to another person?,,Name of person,text,
|
||
Oncology,,May we give information about your health to another person?,,Relationship to you,text,
|
||
Oncology,Does anyone from Home Health or Hospice visit you at home?,,,,radio,"yes,no"
|
||
Oncology,Have you been able to continue most of your normal activities?,,,,radio,"yes,no"
|
||
Neurology, Atrial fibrillation,,,,checkbox,
|
||
Neurology,Bowel Problems,,,,checkbox,
|
||
Neurology,Crohn’s Disease,,,,checkbox,
|
||
Neurology,Loss of consciousness,,,,text,
|
||
Neurology,Parkinson’s Disease,,,,checkbox,
|
||
Neurology,Fibromyalgia,,,,checkbox,
|
||
Neurology,Stomach Ulcers,,,,text,
|
||
Neurology,Neck Surgery,,,,checkbox,
|
||
Neurology,Back Surgery,,,,checkbox,
|
||
Neurology,Aneurysm Surgery,,,,checkbox,
|
||
Neurology,Abdominal Surgery,,,,checkbox,
|
||
Neurology,Bowel Surgery,,,,checkbox,
|
||
Neurology,Bypass in the legs,,,,checkbox,
|
||
Neurology,Gallbladder Surgery,,,,checkbox,
|
||
Neurology,Gastric bypass surgery,,,,checkbox,
|
||
Neurology,Gynecologic surgery,,,,checkbox,
|
||
Neurology,Implants Type,,,,text,
|
||
Neurology,Intrathecal Pump,,,,checkbox,
|
||
Neurology,Pacemaker Surgery,,,,checkbox,
|
||
Neurology,Stimulator,,,,checkbox,
|
||
Neurology,Use caffeine,,,,checkbox,
|
||
Neurology,Street Drug,,,,text,
|
||
Neurology,Dementia,,,,radio,"yes,no"
|
||
Neurology,Epilepsy,,,,radio,"yes,no"
|
||
Neurology,Migraine Headaches,,,,radio,"yes,no"
|
||
Neurology,Polyneuropathy,,,,radio,"yes,no"
|
||
Neurology,Tremor,,,,radio,"yes,no"
|
||
Neurology,Poor memory,,,,checkbox,
|
||
Neurology,Difficulty finding words,,,,checkbox,
|
||
Neurology,Frequent sore throat,,,,checkbox,
|
||
Neurology,Hoarseness,,,,checkbox,
|
||
Neurology,Discharge from nose,,,,checkbox,
|
||
Neurology,Repeated sinus infections,,,,checkbox,
|
||
Neurology,Palpitations,,,,checkbox,
|
||
Neurology,Irregular heart beat,,,,checkbox,
|
||
Neurology,Cold hands,,,,checkbox,
|
||
Neurology,Cold feet,,,,checkbox,
|
||
Neurology,Chronic cough,,,,checkbox,
|
||
Neurology,Muscle loss,,,,checkbox,
|
||
"Neurology,urology",Excessive thirst,,,,checkbox,
|
||
Neurology,Farsighted,,,,checkbox,
|
||
Neurology,Nearsighted,,,,checkbox,
|
||
Neurology,Changes in hair,,,,checkbox,
|
||
Neurology,Changes in nails,,,,checkbox,
|
||
Neurology,Changes in skin color,,,,checkbox,
|
||
Neurology,Dry skin,,,,checkbox,
|
||
Dermatology,"Over the last week, how itchy, sore,painful or stinging has your skin been?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Dermatology,"Over the last week, how embarrassed or self conscious have you been because of your skin?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Dermatology,"Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Dermatology,"Over the last week, how much has your skin influenced the clothes you wear?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Dermatology,"Over the last week, how much has your skin affected any social or leisure activities?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Dermatology,"Over the last week, how much has your skin made it difficult for you to do any sport?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Dermatology,"Over the last week, has your skin prevented you from working or studying?",,,,radio,"yes,no"
|
||
Dermatology,"If ""No"", over the last week how much has your skin been a problem at work or studying?",,,,radio,"A lot,A little,Not at all"
|
||
Dermatology,"Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Dermatology,"Over the last week, how much has your skin caused any sexual difficulties?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Dermatology,"Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time?",,,,radio,"Very much,A lot,A little, Not at all"
|
||
Urology,Are you interested in smoking cessation counseling?,,,,radio,"yes,no"
|
||
Urology,Living Will or Power of Attorney,,,,checkbox,
|
||
Urology,Living Will or Power of Attorney,,,,checkbox,
|
||
Urology,Surrogate Designation (name/relation),,,,text,
|
||
"Medical History, Family history,Urology",Anesthesia Problems,,,,checkbox,
|
||
"Medical History, Family history,Urology",Urolithiasis (Urinary Stones),,,,checkbox,
|
||
Urology,extreme and insatiable hunger,,,,checkbox,
|
||
Urology,genital pain,,,,checkbox,
|
||
Urology,the sensation of pain and/or burning,,,,checkbox,
|
||
Urology,Urinary incontinence problem,,,,checkbox,
|
||
Urology,Genital Sore,,,,checkbox, |