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GENERAL HEALTH QUESTIONS

ENVIRONMENTAL AND LIFESTYLE

Indicate the amount of alcoholic beverages you consume in a:

ALLERGIES:

FAMILY HISTORY

Please complete the following table to the best of your knowledge. Please mark below if there is a personal or family history of any of the following cancers. If yes, then indicate family relationship and age at diagnosis in the appropriate column. Consider parents, children, brothers, sisters, grandparents, aunts, uncles, and cousins.

Mother:

Father:

Siblings:

Maternal grandmother:

Maternal grandfather:

Paternal grandmother:

Paternal grandfather:

MEDICATIONS

PAST MEDICAL HISTORY AND CURRENT MEDICAL CONDITIONS

Please check all that apply to you. The symptoms are grouped to specific body systems and will help us decide where to focus treatment.

B. CANCER