1. What is your name?

(Wat is yur name)

2. What is your birthday? (Wat is yur birday)
3. How old are you? (Jaw ol ar yu)
4. What is your sex? (Wat is yur sex)
5. What symptoms do you have? (Wat simptons do yu have)
6. Are you allergic to any drugs? (Ar yu ellergic tu any drogs)
7. Are you taking any medication? (Ar yu taiking any mediqueishon)
8. What is the name of the drug? (Wat is de name of de drog)
9. What is the dose of this medicine? (Wat is de dos of des medesen)
10. How long have you been taking this? (Jow long have you been taiking des)
11. What disease do you suffer? (Wat dizis do yu soffer)
12. What is your highest education? (Wat is yur jaiest egiqueishon)
13. What is your marital status? (Wat is yur meritel stades)
14. What is your current or past occupation? (Wat is yur current or past akiupeishn)
15. Are you currently working? (Ar yu kurentli working)
16. Do you receive disability or SSI? (Du yu ruisiv disubiluti or es es ai)
17. What religion do you practice? (Wat religen du yu practice)
18. Are your parents alive? (Ar yur parents alaiv)
19. How years old are they? (Jow years old ar they)
20. Do they have any disease?