Form 0920 Personal History

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)

2. 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

4. 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	______