What ___ your name (to be)? ____ you (to marry) ______________ ? How long ______you (to marry) _____________ ? ____ you (to divorce) ______________ ? How long ______you (to divorce) _____________ ? ____ you (to separate) _______________ ? How long ______you (to separate) _____________ ?____ you (to widow) ___________ ? How long ______you (to widow) _____________ ?What _____ your address (to be) ? What _____ your occupation (to be) _____ ? What _____ you (to do) ___________ ? ______ you (to be) single? What _____ your education (to be)? ? When and where _____ you (to bear) ________________? Where ______ you (to live) __________________________ ? What ______ your social security No.?
How ______your father’s (mother’s, sister’s, brother’s) state of health (to be)? ______ you (to have) ___________________ allergies, asthma, anemia, blood clotting problems, diabetes, cancer, tumor, epilepsy, glaucoma, genetic diseases, alcoholism, kidney or bladder trouble, stomach ulcer, duodenal ulcer, rheumatism or arthritis, high blood pressure, heart trouble, gout?
How _____ your spouse’s [spauz] health (to be)? How ______your children’s health (to be)? ______ you ever (to have) _____________ infections? ______you ever (to hospitalize) ____________________ ? When __________ your most recent hospitalization (to be)? When ______ your first (second, third, fourth) hospitalization (to be)? What illness (operation)_______ you (to hospitalize) __________________ for? _________you (to have) _____________ chest x-ray lately? When ______ you last (to give) ___________ chest x-ray? _______ you now (to take) _________________ antibiotics? _______ you (to be) _______sensitive or allergic to antibiotics? _______you (to have)_____________ any skin problems? ______ your skin (to itch or to burn) ____________________________? ______ you (to have) __________________ trouble stopping even a small cut from bleeding? ______ you (to bruise) ________________ easily? _________ you ever (to faint or to feel faint) _______________________________? _______ any part of your body (to be) ________________ always numb? ________ you ever (to have) _____________ seizures or convulsions? _______you (to have) _____________ a tendency to shake or tremble? _______ you (to be) _______________ very nervous around strangers? _________ you (to find) ___________ it hard to make decisions? _______ you (to find) ___________ it hard to concentrate or remember? _____you usually (to feel) _______________ lonely or depressed? ______you often (to cry) ________________? ______you (to have) ______________ difficulty relaxing? ______you have a tendency to worry much? ______you (to trouble, to disturb, to bother) ______________________by frightening dreams or thoughts? _______ you (to have) __________________ a tendency to be shy or sensitive? ________ you (to have) ________________ a strong dislike for criticism? ______ you often (to lose) _______________ your temper? _________little things often (to annoy) _____________ you? ______ you (to trouble, to disturb, to bother) _____________by any work or family problems? _____ you (to have) _______________ any sexual difficulties? ______ you ever (to consider) ___________________ committing suicide? _________you ever (to desire) _______________ psychiatric help? _________you (to gain) __________ or (to lose) ____________ more than 10 pounds in the last 6 months? _______you (to have) ________________________ a tendency to be too hot or too cold? ______ you (to lose) ______________ your interest in eating lately? ______ you always (to seem) ____________ to be hungry? ____________ you (to be) ______________more thirsty than usual lately? _______ there (to be) ______________ any swellings in your armpits or groin? __________you (to seem) __________ to feel exhausted or fatigued most of the time? _____ you (to have) _______________ difficulty either falling asleep or staying asleep? ______ you ( to exercise) _______________ more than three times a week?. How much _____ you (to smoke) ____________ per day? ________you (to take) _____________ two or more alcoholic drinks a day? ______ you (to drink) __________ more than six cups/glasses of coffee, tea or cola soda per day? ______you (to be) a regular user of sleeping pills, marijuana, tranquilizers, and pain killers? ______ you ever (to use) ____________ heroin or cocaine? ______ you (to drive) ___________ a motor vehicle more than 25,000 miles per year? _______ you (to trouble, to disturb, to bother) __________________ by heartburn? _______ you (to feel) ___________ bloated after eating? _______ you (to trouble, to disturb, to bother) ______________ by belching? _______ you (to suffer) _____________ discomfort in your stomach? _____ you easily (to become) ___________ nauseated? ______ you ever (to vomit) _______________ blood? ______ it (to be) difficult or painful for you to swallow? ______ you (to constipate) _________________ more than twice a month? ______ your bowel movements (your stool) (to be) ______ever black or bloody? ______ you (to suffer) ___________ pains when you (to move) ___________ your bowels? _______you (to have) _____________ any bleeding from your rectum? ______ you frequently (to get) __________ up at night to urinate? ______ you (to urinate) ______________ more than five or six times a day? ______ you (to wet) ___________ your pants or (to wet) _________ your bed? ______ you ever (to have) ________________ burning or pains when you (to urinate) ___________?.________ your urine ever (to be) ________ brown, black or bloody? _______ you (to have) _______________ any difficulty starting your urine flow? _______you (to have) ___________________ a constant feeling that you (to have) ______________ to urinate? ______ you (to trouble, to disturb, to bother) ________ with stiff or painful muscles or joints? ______your joints ever (to swell) ___________________? ___________you (to trouble, to disturb, to bother) _______________ by pains in the back or shoulder? ______ your feet (to be) ___________ often painful? ________ you (to handicap) _________________ in any way? _______you (to have) _____________ headaches more than once a week? _________twisting your neck quickly (to cause) ______________ pain? ____________ you ever (to have) __________________ lumps or swelling in your neck? ________ you (to wear) ______________ glasses? ________ your eyesight ever (to blur) ______________? __________your eyesight (to get) ______________ worse? _______you ever (to see) _______________ double? _______ you ever (to see) _____________ colored halos around lights? _____ you ever (to have) ______________ pains or itching in or around your eyes? .______ your eyes (to blink or to water) _____________________ most of the time? ______ you (to have) ____________ any trouble with your eyes in (for) the last two years? ______ you (to have) ______________ difficulty hearing? _______you (to have) __________ any earaches lately?.______ you (to trouble, to disturb, to bother) ______________ by running nose? ________ you (to have) _____________ a repeated buzzing or other noises in your ears? _____you (to get) ______________ motion sickness riding in a car or plane? _____ you (to have) __________ any problems with your teeth? ______ you (to have) ___________ any sore swellings on your gums or jaws? _____your tongue (to be) _______ sore or sensitive? ________your taste senses (to change) _________________ lately? _____ your nose (to stuff up) ____________ when you (not to have) _________________ a cold? _______your nose (to run) ___________ when you (not to have) ______________ a cold? ________ you ever (to have) ___________ sneezing spells? ______you ever (to have) ____________ head colds two or more months in a row? _______ your nose ever (to bleed) ___________ for no reason at all? ______your throat (to be) ________ ever sore when you (not to have) _______________a cold? ______ you (to wheeze) or (to gasp) ______________ to breathe? _____you (to bother, to trouble, to disturb) ____________________ by coughing spells? ________ you (to cough up) _____________ much phlegm? ______you ever (to cough) ______________ up blood? ______you (to get) ______________ chest colds more than once a month? ______ you (to sweat) _________ more than usual or (to have) ___________ night sweats? ________you ever (to tell) _______________________that you (to have) ___________ high blood pressure? ______you (to trouble, to bother, to disturb) ___________________ by a thumping or racing heart? _____ you ever (to get) ________ pains or tightness in your chest? _______you (to have) ________________ trouble with dizziness or lightheadedness? ______you (to wake up) ______________ at night short of breath? ______ you (to use) _____________ more pillows to help you breathe at night? ________you (to have) ___________ trouble with swollen feet or ankles? __________you (to get) ___________ cramps in your legs at night or upon walking? _________ you ever (to tell) ________________that you have a heart murmur?
