Survey Text

1981
top
1981
Survey form view entire document:  text  image

1. During the 2 weeks outlined in red on that calendar, did -- take or use any:

a. Pain relievers such as aspirin (or Tylenol and the like)?
[] Y
[] N
b. Cough medicines (such as Vicks, Robitussin, or Phenergan Expectorant and the like)?
[] Y
[] N
c. Any other medicines or remedies for colds?
[] Y
[] N
d. Asthma or allergy pills or medicines (such as Benadryl, Dimetapp, or Sudafed and the like)?
[] Y
[] N
e. Topical steroids (such as hydrocortisone cream or valisone and the like)?
[] Y
[] N
f. Other skin ointments or salves (such as Desitin, Calomine Lotion, Vaseline, Clearasil and the like)?
[] Y
[] N
g. Laxatives or any other medicines or remedies for the stomach (such as Ex-Lax, Rolaids, Colace, or Donnatal and the like)?
[] Y
[] N
h. Vitamins or minerals?
[] Y
[] N
i. Tranquilizers or sedatives (such as Valium, Chloral Hydrate, or Secanol and the like)?
[] Y
[] N
j. Antibiotics (such as Penicillin, Tetracycline, Ampicillin and the like)?
[]Y
[] N
k. Are there any other pills, ointments, or other types of medicines that -- has taken or used during that 2 week period? - Specific
[] Y
[] N
Any others?
K1 ____
K2 ____
K3 ____