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Old 01-27-2012, 03:57 AM   #29
Constructman
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1: do you have or have you had any of the following :

[ ]Asthma
[ ]Arthritis
[ ]Epilepsy
[ ]Diabetes
[ ]Heart Conditions
[ ]Heart Disease
[ ]Kidney disorders
[ ]Chronic Fatigue Syndrome
[ ]Anemia
[ ]High Blood Pressure
[ ]High Cholesterol
[ ]Cancer
[ ]Autoimmune disorders
[ ]STD's
[ ]Osteoporosis
[ ]Stroke
[ ]Vision problems (not counting glasses)
[ ]Wear glasses
[ ]Auditory problems
[ x]Dental problems (including need for braces)
[ ]Hydrocephalus
[ ]Cerebral Palsy
[ ]Spina Bifida
[ ]Other birth defects
[ ]Anything else you think should be listed

(further information on any check marks)

2: Do you have a family history of any of the following:

[ ]SIDS
[ ]Asthma
[ ]Arthritis
[ ]Epilepsy
[ ]Diabetes
[ ]Heart Conditions
[ ]Heart Disease
[ ]Kidney disorders
[ ]Chronic Fatigue Syndrome
[ ]Anemia
[ ]High Blood Pressure
[ ]High Cholesterol
[x]Cancer
[ ]Autoimmune disorders
[ ]STD's
[ ]Osteoporosis
[ ]Stroke
[ ]Vision problems (Not counting glasses)
[ ]Wear glasses
[ ]Auditory problems
[ ]Dental problems (including need for braces)
[ ]Hydrocephalus
[ ]Cerebral Palsy
[ ]Spina Bifida
[ ]Other birth defects
[ ]Anything else you think should be listed

(list family relation of any with checkmark, and further information)


3: Do you have any of the following:

[ ]Mental illness
[ ]Depression
[ ]Learning disabilities
[ ]Mental Retardation
[x]Autism Spectrum Disorders (including Aspergers syndrome)
[ ]Alcoholism or other substance abuse
[ ]Any other addictions
[ ]Exceptionally intelligent

Anything else you want us to know about

4: Do you have a family history of:

[ ]Mental illness
[ ]Depression
[ ]Learning disabilities
[ ]Mental Retardation
[ ]Autism Spectrum Disorders (including Aspergers syndrome)
[ ]Alcoholism or other substance abuse
[ ]Any other addictions
[ ]Exceptionally intelligent

Anything else you want us to know about

5: Do you smoke?
No

6: DO you drink?
No

7: Do you use any other recreational drugs?
No

8: Are you on any long term medications?
No

9: How often and what kind of over the counter medications?
None

10:How much caffeine?
(per day)
0-2 cups of hot chocolate/tea per day

11: DO you drink energy drinks?
No

12: Qualify your diet (poor, ok, good, excellent)
good

13: How many times a week to you work out?
0

14: How active are you?
Moderate

15: Generally, how healthy are you?
Good

16: Have you ever broken, sprained, strained or torn any bones/muscles/ligaments/tendons
No?

17: Have you ever needed stitches?
No

18: Any significant early childhood trauma, emotional or physical?
Does having pleural empyema at the age of 4-5 count?

19a females:
age of menarche (age of first period)
N/A

Do you have a regular cycle
N/A

Have you ever been pregnant
N/A

Number of
Abortions
N/A

miscarriages
N/A

stillbirths
N/A

vaginal live births
N/A

C sections
N/A

Age of menopause (if appropriate)
N/A

Age you became sexually active
N/A

19b males:

Age of puberty onset
11-12

Erectile dysfunctions
No

Age you became sexually active
Have not become sexually active yet

normal sperm count (if known)
Umm... How am I supposed to know this?
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Last edited by Constructman; 01-27-2012 at 03:59 AM. Reason: Wrong answer
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