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THE JOHNS HOPKINS CENTER FOR CEREBROSPINAL FLUID DISORDERS ADULT HYDROCEPHALUS PROGRAM
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This questionnaire can take between 10-45 minutes depending on your individual medical history.
We understand you have probably filled hundreds of similar pages but it is important for us to know your complete medical history. The physician you end up seeing at our center and the type of diagnostic testing and treatment depends on accurate answers to these questions.
This is the description of your section break.
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PATIENT INFORMATION:
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Sex *
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Ethnicity *
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Race (check all that apply) *
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Handedness *
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Is your address within the United States? *
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Please identify a responsible family member, guardian or person we can contact:
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Do you reside in an Assisted Living, Rehabilitation, or Skilled-Nursing
Facility? *
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Please provide the following information about your Assisted Living, Rehabilitation, or Skilled-Nursing
Facility:
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Do you have a referring physician? *
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Physician Referral
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A special link to resume the form will be sent to your email address.
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