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How many grades?
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Which grade(s)? (List up to 3 most recent grades)
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Does your child have any accommodations because of learning differences?
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Describe
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About how long have you been in the United States?
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Estimate the number of units (pints) of blood that you have ever received. (Select one).
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As you know, the XX Study will be describing all medications its participants are using, both prescription and over-the-counter. These include pills, liquid medications; skin patches, eye drops, creams, salves, inhalers and injections, as well as cold or allergy medications, vitamins, herbal remedies and other supplements. The letter you received about this appointment included a plastic medications bag for all your current medications and asked you to bring them to the clinic. Have you brought this bag with you? Are these all the medications that you have taken in the past two weeks?
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Prescription/Over-The-Counter Medications
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Medication Name
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Strength (mg, IU, etc.)
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Number prescribed
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Day, Week, Month
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PRN Medicine?
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On the average during the last two weeks, how many of these pills did you take a day/week/month
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day/week/month
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Prescription medications number unable to transcribe
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Over-the-Counter medications number unable to transcribe
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In your entire life, have you had at least 1 drink of any kind of alcohol, not counting small tastes or sips?
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Have you ever tried cigarette smoking, even one or two puffs?
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When was the last time you smoked a cigarette, even one or two puffs?