Bioscience Research Institute

cancer Treatments

Med History Form

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Fill in the questionnaire







First Name:
Last Name:
Age:


Place of residence
Country:








List your three main health issues


In your opinion, what might have contributed or caused some of your health issues



When did you start having these issues?



How physically independent are you?

Totally Independent

I need help from others to move from one place to another

Are you taking medication or nutritional supplements? Describe



City:
Telephone number:
Gender Male Female

Weight and Height
Weight(pounds)
Height (feet)
Date of Birth (mm/dd/yy)

Genetic Background

Caucacian
Latin American
Asian
African American
Indigenous / Native American

Primary Diagnosis
What is your primary diagnosis?



how long ago where you diagnosed?



What treatments have you taken for it?





Medical History Form
 

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