Medical Questionnaire

This questionnaire is being administered as a part of a study designed to develop strategies and procedures that will lead to higher levels of compliance by tuberculosis patients with prescribed treatment regimens. There are no "right" and "wrong" answers to the questions that you are asked to answer. Similarly, there are no penalties associated with any answer you provide to any of the questions. All of your responses will be treated with confidence. No records will be maintained that will permit anyone to related a specific response to a specific question to a specific individual making that response. Please answer all questions, and please give truthful answers to all questions.

( ) Under 25 years ( ) 25-34 years

( ) 35-49 years ( ) 50-64 years

( ) 65-74 years ( ) 75 years or older

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Category: Misc - M