I. Profile: Please check or supply the information needed
Name: ____________________________ Gender: Male Female
Age: ______
II. Screening Questions: Please fill-up the necessary information on the blank and check the option which best applies to you.
1. Do you smoke cigarette? Diabetes insipidus
YES Gestational diabetes How often do you smoke? _____ NO NO 2. Do you drink alcohol? 6. Are you taking any medications? YES YES If yes, when was your last alcohol intake? If yes, please check: ______ Aspirin NO Celecoxib Diclofenac 3. Do you feel stress right now? YES Sibuprofen How often do you feel stress?_____ Coumadin (Warfarin) Cause/s: Heparin Love life: Others: please specify: ______ School: NO Family: 7. Do you have any liver-related disease? YES Others, please specify: _____ If yes, please check: NO Cirrhosis Hepatitis 4. Are you suffering from any Others, please specify: _____ cardiovascular diseases? YES NO If yes, please check: Congenital heart disease 8. Do you have any blood-related disease? YES Arrhythmia If yes, please check: Cardiomyopathy Anemia Vascular disease Leukemia Myocardial infarction Hemophilia If others, please specify: ______ Thalassemia NO Thrombocytopenia Others: please specify: ______ 5. Are you suffering from diabetes? YES NO If yes, please check: Diabetes mellitus