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Family Members Describe Stroke/TIA High Blood Pressure High Cholesterol or Triglycerides Liver Disease Alcohol or Drug Abuse Anxiety, Depression or Psychiatric Illness Tuberculosis Anesthesia Complications Genetic Disorder Other – describe Other – describe Other - describe Other information about your family which you want us to know: Healthcare Provider Information Do you have a Primary Care Provider No Yes → Name Phone ( ) Address Do you want a summary of your visit sent to this person No Yes Did a non-Vanderbilt physician or healthcare provider recommend or arrange this visit for you No Yes → Who sent you Your Primary Care Provider (as listed above) Other physician or healthcare provider (record name, phone and address below) Name Phone ( ) Address Do you want a summary of your visit sent to this person No Yes Page 4 of 5 Medications Are you currently taking any prescription and/or non-prescription medications including vitamins, nutritional supplements, oral contraceptives, pain relievers, diuretics, laxatives, herbal remedies, and cold medications No Yes → List medications below: Name of Medication Dose How Often Taken Are there other medications you have recently used No Yes → List medications: Have you taken aspirin-containing products in the last two weeks No Yes Have you taken steroid or cortisone-type drugs within the last year No Yes For Medical Team Use Only: Allergies Have you had hives, skin rash, breathing problems, or other allergic reactions to medications No Yes → List medications below: Name of Medication Are there medications, other than those you are allergic to, that you would prefer not to take due to prior unpleasan
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