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MEDICAL HISTORY Yes / No Unknown If Yes, Explain Current / ResolvedHead, Eye, Ear, Nose, Throat FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX   FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedRespiratory  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedCardiovascular  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedGastrointestinal FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedGenitourinary  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedMusculoskeletal  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedNeurological  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedEndocrine-Metabolic  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedBlood/Lymphatic  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedDermatologic  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedPsychiatric  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedAllergy  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  ResolvedOther, specify: ___________ FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  FORMCHECKBOX  Current  FORMCHECKBOX  Resolved     Medical History Medical History Version 1.0    !R^_} 񮛇tdtZMBMBh\5OJQJ^Jhnh\OJQJ^Jh\CJmH sH h\CJOJQJ^JmH sH $hnh\CJOJQJ^JmH sH 'hnh\>*CJOJQJ^JmH sH $hnh\CJOJQJ^JmH sH hnh\5CJOJQJ^Jhnh\CJOJQJ^Jh/5OJQJ\^J h\5\hnh\5OJQJ\^Jhnh\5OJQJ^J  !"9:v___KKK<$&P#$/Ifgd\$x$&P#$/Ifa$gd\rkd$$Ifl^E++$$ 6P0+64 lap $($&P#$/Ifa$gd\:;R^_i x$&P#$/Ifgd\ Wx$&P#$/If^`Wgd\" B < <$&P#$/Ifgd\& B < <$&P#$/If]gd\<$&P#$/Ifgd\! 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Arial NarrowA BCambria Math"1hbGbGbGIWIW!r4d3qHX?M2!xxMEDICAL HISTORYKAI Research, Inc. Lori Anderson Oh+'0  < H T `lt|MEDICAL HISTORYKAI Research, Inc. Normal.dotmLori Anderson2Microsoft Office Word@@TH@TH@THIW՜.+,D՜.+,< hp|  KAI MEDICAL HISTORY TitlepH(H\d_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_PreviousAdHocReviewCycleID_ReviewingToolsShownOnceq6Medical History .docbcase@kai-research.com Brian Case*?  !"#$%&'()*+,./0123456789:;<=>?@ABCEFGHIJKLMNOPQRSTVWXYZ[\^_`abcdgRoot Entry Fp5HiData -\-1TableD!WordDocument4XSummaryInformation(UDocumentSummaryInformation8]CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q