HealthScreen Questionnaire - Clark College
Part 2 – Signs and Symptoms ... No Yes Has your father, mother, brother, or sister had a heart attack, heart surgery, or sudden death before the age of 55 (male) or 65 (female)? No Yes Do you smoke cigarettes on a daily basis, or have you quit smoking recently (within the past 6 months)? No Yes If yes, about how many cigarettes do you smoke ... ................
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