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Questionnaire

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