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Unformatted text preview: Original Date: Dates Revised: GENERAL QUESTIONNAIRE All questions contained in this questionnaire are strictly for research purpose and would be maintained purely confidential Name (Last, First, M.I.): M F DOB: Marital status: Single Partnered Married Separated Divorced Widowed Previous or referring doctors degree: Date of last physical exam: PERSONAL HEALTH HISTORY List any medical problems that other doctors have diagnosed Surgeries Year Reason Hospital Other hospitalizations Year Reason Hospital Have you ever taken any type of vitamin supplement Yes No Reason for not ever taking a supplement: 1.)Never felt the need to take: 1....
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- Spring '11