Document 2vexjbe0m2BwJYgY1Qm13K4L

Study ID Number _ _ _ __ Name _ _ __ MHD Drug Use History MHD 1 Do you have asthma or other allergies requiring treatment? 1. [J No 2. [J Yes 3. D Do not know If yes, what drugs have you taken for asthma or allergies?_ _ _ __ MHD2 Have you ever been treated with radiotherapy for cancer? 1. No D 2. YesD 3. D Do not know MHD22 If yes, Number of times _ _ _ _ __ MHD23 Dates from to _ _ _ __ MHD24 Type of cancer treated._ _ _ _ _ _ _ _ _ _ __ MHD 3 Have you ever been treated with chemotherapy for cancer? 1. No D 2. Yes D 3. D Do not know MHD32 If yes, Number of times _ _ _ _ __ MHD33Date from to _ _ _ __ MHD34drugs used _ _ _ _ _ _ __ MHD35Type of cancer treated_____________ MHD4 Have you ever taken any of following medicine for more than one month: 1. No D 2. Yes D 3. D Do not know Check Medications Year How long Year if yes Started stopped Chloramphenicol (Chloromycetin) Sulfonamides Meprobamate Phenatoin (or dilantin) Colchicine Cyclophosphamide Propylthiouracil Anti-TB medication Tolbutamide (D860) Primaquine Chinese traditional herbs MHH 1 List all Chinese traditional herbs that you have taken for more than one month: 1. No D 2. Yes D 3. D Do not know Check Chinese traditional herbs Year How long Year if yes Started stopped Bezoar Angelica Arsenic: Arsenic Sulphide, Arsenic Oxide, Organic arsenic compounds Thunder cloud vine Any lead containing tablets or preparations Version 24 February 2004 CC_DP Questionnaire 6 of 15 SH ELL-MCCLU RG-059284