Cardiovascular (heart) 4 ongoing Part II: Body System Medical History Ask if the participant ever experienced any significant medical problems involving the following organ/systems. If response is YES, include onset and outcome (if resolved) dates, severity grade, medications taken, and any comments relevant to the diagnosis/description. Onset Outcome Severity # Body System No Yes Med. Description/Comments Date Date Grade Respiratory (lungs) 5 ongoing Liver 6 ongoing Renal (bladder, kidney) 7 ongoing Gastrointestinal 8 ongoing Musculoskeletal (including bone 8 fractures) ongoing Neurologic 9 ongoing Skin 10 ongoing Endocrine (hormones)/Metabolic 11 ongoing
4 Cardiovascular (heart) ongoing Part II: Body System Medical History Ask if the participant ever experienced any significant medical problems involving the following organ/systems. If response is YES, include onset and outcome (if resolved) dates, severity grade, medications taken, and any comments relevant to the diagnosis/description. # Body System No Yes Onset Date Outcome Date Severity Grade Med. Description/Comments 5 Respiratory (lungs) ongoing 6 Liver ongoing 7 Renal (bladder, kidney) ongoing 8 Gastrointestinal ongoing 8 Musculoskeletal (including bone fractures) ongoing 9 Neurologic ongoing 10 Skin ongoing 11 Endocrine (hormones)/Metabolic ongoing
MTN-026%20Baseline%20Medical%20History%20Questions%20Form.docx