Diagnose-Me - Page 7(j) - Male Questionnaire

MALE QUESTIONNAIRE - PAGE 7(j)

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This sections deals with various medications that have not been covered elsewhere. You may list further medications in the notes box below.

834.

Blood Thinners: Are you currently using either Coumadin or Warfarin?

	No / don't know
	Yes

835.

Caffeine in powder, tablet or injection form (used to restore mental alertness or overcome drowsiness/weakness).

	Never / don't know
	Some use (under 1000mg per day) in the past only
	Heavy use (over 1000mg per day) in the past only
	Currently using some (under 1000mg per day)
	Currently using high doses (over 1000mg per day)

Add any additional information here for the questions above:

Please mention the question number(s) if possible.