Form 0920 Personal History

A Longitudinal Examination of Mental and Physical Health among Police Associated with COVID–19

Attachment D1- Personal History

Att D1- Personal History

OMB: 0920-1350

Document [docx]
Download: docx | pdf






Attachment D2

Medical History











Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

II. Medical History




1. In general, would you say your health is:

(1) Excellent

(2) Very good

(3) Good

(4) Fair

(5) Poor



2. Compared to your last visit to UB, how would you rate your health in general now?

(1) Much better now than at last visit

(2) Somewhat better now than at last visit

(3) About the same

(4) Somewhat worse now than at last visit

(5) Much worse now than at last visit



3. What was your weight one year ago? _______ pounds



4. How long has it been since you last saw a physician for any reason (approximately)?

(1) Within the last 1 year

(2) 1 to 3 years ago

(3) 3 to 5 years ago

(4) More than 5 years ago



5. How often do you have a routine physical examination, that is, an exam by a doctor or health care professional,

not for a particular illness, but for a general checkup?

(1) Do not have routine physical examinations

(2) Less than once every five years

(3) At least once every five years

(4) At least once every year




Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).


6. Have you been told by a doctor or health care professional that you have high blood pressure?

(0) No (1) Yes (3) Don’t Know


If NO or Don’t Know, go to Question 7



  1. If YES, how old were you when you were first told by a medical professional that you had high blood pressure?

__ __ years old. (93) Don’t Know

B. For women only: If YES, did this condition exist only when you were pregnant?

(0) No (1) Yes (3) Don’t Know (8) Not Applicable


C. Are you currently being treated for high blood pressure?

(0) No (1) Yes (3) Don’t Know


D. If you are being treated for high blood pressure, do you currently take:

(10) Maxzide (27) Lisinopril

(13) Zestril (33) Diovan

(17) HCTZ (44) Diovan HCT

(18) Atenolol (36) Lotrel

(20) Accupril (37) Toprol, Toprol XL

(21) Norvasc (47) Metoprolol

(24) Verapamil (87) Other___________________






7. Have you been told by a doctor or health care professional that you have high cholesterol?

(0) No (1) Yes (3) Don’t Know


If NO or Don’t Know, go to Question 8


  1. If YES, how old were you when you were first told by a medical professional that you had high cholesterol?

__ __ years old. (93) Don’t Know

B. Are you currently being treated with medication for high cholesterol?

(0) No (1) Yes (3) Don’t Know


C. If you are being treated for high cholesterol, do you currently take:

(1) Lipitor (22) Vytorin

(10) Lovastatin (24) Simvastatin

(20) Crestor (87) Other ___________________




8. Have you been told by a doctor or health care professional that you have high or elevated sugar in blood or urine?

(0) No (1) Yes (3) Don’t Know


If NO or Don’t Know, go to Question 9


A. If YES, how old were you when you were first told by a medical professional that you had elevated sugar in blood or urine?

__ __ years old. (93) Don’t Know





9. Have you been told by a doctor or health care professional that you have diabetes?

(0) No (1) Yes (3) Don’t Know

If NO or Don’t Know, go to Question 10


  1. If YES, Was this (1) Insulin Dependent Diabetes (Type 1) or

(2) Non-Insulin Dependent Diabetes (Type 2)

  1. If YES, how old were you when you were first told by a medical professional that you had diabetes?

__ __ years old. (93) Don’t Know

C. If YES, what type of treatment are you taking for your diabetes?

(1) insulin injections (4) by exercise

(2) oral hypoglycemic agent (pill) (5) by doing nothing

(3) by dietary control (6) other

  1. If you are taking an oral hypoglycemic agent (pill), for diabetes, do you currently take:

(1) Glucotrol (13) Metformin

(2) Diabinese (16) Glyburide

(4) Glucophage (17) Avandamet

(10) Avandia (87) Other ___________________


E. For women only: If YES, did this condition exist only when you were pregnant?

(0) No (1) Yes (3) Don’t Know (8) Not Applicable


10. If you have been told by a doctor or health care professional that you have or have had any of the listed conditions, please check "Yes" and fill in the other items. Check "No" if you have never been told that you have the condition.






Condition


No

(0)


Yes

(1)

If Yes,

Age First Diagnosed

1

Angina (chest pain related to your heart)

No

Yes

__ __




If yes, was the angina confirmed by angiogram?


No

Don't

Know



Yes


2

Heart attack (myocardial infarction, MI)

No

Yes

__ __


Number of times this occurred ________




3

Atrial fibrillation (special type of irregular heart beat)

No

Yes

__ __

4

Irregular heart beat (arrhythmia)

No

Yes

__ __

5

Diseased heart valve

No

Yes

__ __

6

Rheumatic heart disease

No

Yes

__ __

7

Congestive heart failure

No

Yes

__ __

8

Stroke

No

Yes

__ __


Number of times this occurred ________




9

Transient ischemic attack (T.I.A., ”mini-stroke”)

No

Yes

__ __


Number of times this occurred ________




10

Peripheral vascular disease (intermittent claudication or leg pain on exercise, but not varicose veins)

No

Yes

__ __

11

Deep venous thrombosis (blood clots in your legs, but not varicose veins)

No

Yes

__ __

12

Aortic aneurysm (thinning in the wall of the big artery going to the heart)

No

Yes

__ __

13

Pulmonary embolus (blood clot in the lung)

No

Yes

__ __

14

Childhood asthma

No

Yes

__ __

15

Lung problems as a child (e.g. multiple cases of pneumonia or bronchitis) Please describe:


______________________________

No

Yes

__ __

16

Asthma as an adult

No

Yes

__ __

18

Chronic bronchitis

No

Yes

__ __

19

Emphysema

No

Yes

__ __

20

Pneumonia

No

Yes

__ __

21

Tuberculosis (TB)

No

Yes

__ __

22

Pleurisy (inflammation of the lining of the lungs)

No

Yes

__ __

23

Fibrotic lung disease (Fibrosis)

No

Yes

__ __

24

COPD (Chronic Obstructive Pulmonary Disease)

No

Yes

__ __

25

Other chronic lung disease: (Please describe)

______________________________________________

No

Yes

__ __

26

Gall bladder disease

No

Yes

__ __

27

Kidney or bladder stones

No

Yes

__ __

28

Kidney disease (Specify _____________________)

No

Yes

__ __

29

Jaundiced

No

Yes

__ __

30

Hepatitis

No

Yes

__ __

31

Liver cirrhosis

No

Yes

__ __

32

Polyps in your colon or rectum

No

Yes

__ __

33

Broken bones as an adult (includes stress fractures)

No

Yes



If yes, please specify which bone and age at time of fracture:


Bone:_______________________________ Age:________


Bone:_______________________________ Age:______

Bone:_______________________________ Age:________


Bone:_______________________________ Age:_______





34

Osteoporosis (thinning bones)

No

Yes

__ __

35

Osteoarthritis (degenerative joint disease)

No

Yes

__ __

36

Rheumatoid arthritis

No

Yes

__ __

37

Systemic lupus erythematosus (Lupus)

No

Yes

__ __

38

Polymyalgia

No

Yes

__ __

39

Sarcoidosis

No

Yes

__ __

40

Other immune disease

No

Yes

__ __

41

Thyroid disease

Hyperthyroidism

Hypothyroidism

Don’t Know

No

Yes

__ __

42

Parathyroid disease

No

Yes

__ __

43

Seizures

No

Yes

__ __

44

Depression

No

Yes

__ __

45

Any neurologic disease

No

Yes

__ __

46

Benign breast disease

(non-cancerous, includes fibrocystic breast disease, fibroids, cystic breast or mastitis)

No

Yes

__ __

47

Cancer In-Situ (localized cancer that does not usually spread)


Where:____________________________________

No

Yes

__ __

48

Skin cancer

No

Yes

__ __

49

Any other type of cancer, not skin cancer (Please describe):


______________________________

______________________________

No

Yes

__ __


50

Are you currently undergoing treatment for cancer?

If YES, what type of treatment?

Chemotherapy

Radiation therapy

Hormone therapy

Other (Please specify___________________)

No



No

No

No

No


Yes



Yes

Yes

Yes

Yes


51

Have you had any other disease (Please describe):

______________________________________________

______________________________________________




No



Yes



__ __

This next question deals with medical procedures which you may have had. For each item, check "Yes" if you have had the procedure, "No" if not. If you check "Yes", please write in the date of your most recent procedure.


Procedure

No

(0)

Yes

(1)

Most Recent Year

1

EKG/ECG (electrical tracing of heart's activity)

No

Yes

______

2

Echocardiogram (ultrasound of the heart and its chambers)

No

Yes

______

3

Stress test (such as an exercise stress test)

No

Yes

______

4

Doppler test (an ultrasound of blood vessels)

No

Yes

______

5

Angiogram or cardiac catheterization (heart catheterization or coronary angiogram)

No

Yes

______

6

Carotid endarterectomy (opening of blockage or narrowing of the arteries in your neck)

No

Yes

______

7

Clot dissolving treatment to prevent or reduce heart attack (sometimes called TPA or streptokinase therapy)

No

Yes

______

8

Atherectomy (sometimes referred to as "roto-rooter")

No

Yes

______

9

Angioplasty of coronary arteries (opening arteries of the heart with a balloon- sometimes called PTCA)

No

Yes

______

10

Stent inserted

No

Yes

______




If yes, location of stent: Coronary artery

Carotid artery



No

No



Yes

Yes



______

______

11

Heart bypass surgery or coronary bypass surgery for blocked or clogged arteries

No

Yes

______

12

Heart valve repair/replacement

No

Yes

______

13

Pacemaker

No

Yes

______

14

Bronchoscopy (exam of your lungs with a small scope)

No

Yes

______

15

Colonoscopy (exam of your colon with a small scope)

No

Yes

______

16

Bone Density Test

No

Yes

______

17

Chest x-ray

No

Yes

______


If yes, about how many chest x-rays have you had in your life: ______




18

X-ray of the spine or back (to see curvature of the spine)

No

Yes

______


If yes, about how many back x-rays have you had in your life: ______




19

Dental x-ray

No

Yes

______


If yes, about how many dental x-rays have you had in your life: ______




20

Other x-ray/radiation treatment (not diagnostic)

Reason______________________________________

No

Yes

______




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSawyer, Tamela (CDC/NIOSH/OD/ODDM)
File Modified0000-00-00
File Created2021-07-30

© 2024 OMB.report | Privacy Policy