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Get UTSW Form OBC/FRHPQ-001 2008-2024

Es Yes Please list medications you are currently taking: Surgical History List all surgeries, location and approximate dates: Social/Dietary History Do you use or have you ever used (check all that apply): Alcohol If so, how many glasses per week do you usually drink? Wine Caffeine If so, how many cups coffee/tea and/or cans of soda a day? Cigarettes If so, how many cigarettes per day? Recreational drugs If so, please name: Has your weight changed more than 15 lbs. in the last year?.

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