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Requested
Illustration:
1.
THE
DATE OF CLIENT'S FIRST STROKE: Month
Year
2.
THE DATE OF CLIENT'S LAST STROKE: Month
Year
3.
NUMBER OF STROKES SUFFERED DURING THE LAST 24 MONTHS:
4.
HAS
THE CLIENT EVER HAD CAROTID ARTERY SURGERY AS THE RESULT
OF A STROKE?
IF YES, PLEASE DETAIL:
5.
DATE OF THE LAST STRESS EKG:
6. LIST THE LAST CHOLESTEROL READING, IF
KNOWN:
HDL RATIO
7.
LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC
DIASTOLIC
8.
CLIENT'S OCCUPATION
9.
HAS
A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER
THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
10.
DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
11.
PLEASE
LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY
AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE
DOSAGE AND FREQUENCY OF EACH:
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