PatientInformationV4_0

PatientInformationV4_0 - OFFICE USE ONLY Project ID: __ __...

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Unformatted text preview: OFFICE USE ONLY Project ID: __ __ __ __ __ __ __ Date: __ __/__ __/ 20__ __ Patient ID: __ __ __ __ Code: __ __ Visit week: 0 4 8 12 This booklet asks you questions about you and your health. If you have any questions, please ask the Study Coordinator for help. 1. What is your date of birth? __ __/__ __/19__ __ 2. What is your race? 1 American Indian 3 Black or African American 5 Mixed Race 2 Asian or Pacific Islander 4 Hispanic 6 White 3. Please check your highest educational level: 1 Some High School 3 Some College 5 Post Graduate Degree 2 High School Diploma 4 College Degree 6 Professional School 4. What is your occupation? _________________________________________________________________ 5. Please check the box that applies. 1 Single 2 Married/living with partner 3 Divorced 4 Widowed 6a. How many pregnancies have you had? __ __ 6b. How many of these pregnancies were carried to term? __ __ 7. Are you a Palmer College student? Are you a Palmer College student?...
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This note was uploaded on 01/03/2012 for the course C 504 taught by Professor Long during the Fall '11 term at Palmer Chiropractic.

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PatientInformationV4_0 - OFFICE USE ONLY Project ID: __ __...

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