Other medicines None of the above Hypertriglyceridemia: Yes Unknown No Cancer: Yes Unknown (Skip to 40) No (Skip to 40) Type(s) of cancer: Brain Lung Breast Prostate Colorectal Renal (kidney) Endometrial Skin Esophagus Other, specify: Did you receive head or neck radiation to treat the cancer? Yes Unknown No Infection within two weeks: Yes Unknown No If YES, indicate type(s) (choose all that apply): Respiratory infection Mastoiditis Urinary tract infection (UTI) Viral gastroenteritis Cellulitis Fever lasting > 48 hours Sepsis Other infection, specify: Otitis media Sickle cell anemia: Yes Unknown No If YES, are blood transfusions used as treatment? Yes Unknown No Hypercoagulable disorder: Yes Unknown No If YES, specify type: Bleeding disorder: Yes Unknown No If YES, specify type: Lupus: Yes Unknown No Other connective tissue disease: Yes Unknown No If YES, specify type: Sleep apnea: Yes Unknown No If YES, specify type:
Other medicines None of the above Hypertriglyceridemia: Yes No Unknown Cancer: Yes No (Skip to 40) Unknown (Skip to 40) Type(s) of cancer: Brain Breast Colorectal Endometrial Esophagus Lung Prostate Renal (kidney) Skin Other, specify: Did you receive head or neck radiation to treat the cancer? Yes No Unknown Infection within two weeks: Yes No Unknown If YES, indicate type(s) (choose all that apply): Respiratory infection Urinary tract infection (UTI) Cellulitis Sepsis Otitis media Mastoiditis Viral gastroenteritis Fever lasting > 48 hours Other infection, specify: Sickle cell anemia: Yes No Unknown If YES, are blood transfusions used as treatment? Yes No Unknown Hypercoagulable disorder: Yes No Unknown If YES, specify type: Bleeding disorder: Yes No Unknown If YES, specify type: Lupus: Yes No Unknown Other connective tissue disease: Yes No Unknown If YES, specify type: Sleep apnea: Yes No Unknown If YES, specify type:
F1152_Medical_History.docx