Adult Medical History Form

Attachment 10a

Adult Medical History Form

Survey of CFS and Chronic Unwellness in Georgia

Medical History Form

Affix Case ID Label Here

Date: _____/_____/______

Time: ___________am/pm

1. If you have to list three major problems that you have with your health, what would they be? Please start with what bothers you the most.

Problem/Complaint/Concern	When did this problem start?	Do you still have this health problem?
1.	/ MONTH YEAR	Yes No
2.	/ MONTH YEAR	Yes No
3.	/ MONTH YEAR	Yes No

1a. From the time these problems began until now, how have they changed? If there is such a thing as a typical episode, please describe it. If you have no problems, go to question 2.

Problem 1.

Problem 2.

Problem 3.

PAST MEDICAL HISTORY

2. Before having the problems discussed above, how would you describe your health? (Circle your answer).

Poor Fair Good Very Good Excellent

3. Before age 18, did you have any major childhood health problems? Please include problems that made you go to the doctor more often (not just for “check ups”), go to a hospital, or take medications. These problems include bad infections, reactions to immunizations or vaccinations, and other serious medical problems.

₁ Yes

₂ No → IF NO, GO TO QUESTION 4.

3a. Please describe these childhood health problems you had before age 18 and write below how old were you when you had the health problem. (If you don’t remember your age, give your approximate age or think of political or historic events that were happening at that time to help you remember.) If problems or bad reactions to immunizations happened more than once, list them separately. If you need more space, use another sheet of paper.

Health problems before age 18	Age when problem occurred
1.
2.
3.
4.
5.
6.
7.
8.

4. The next question is about medical problems you have had as an adult (age 18 and over).

Have you had any medical problems for which you saw a doctor regularly? Please include bad infections, reactions to immunizations or vaccinations, and any other medical problems that bothered you.

₁ Yes

₂ No → IF NO, GO TO QUESTION 5

4a. Please describe your medical problems and the age at which you had them. If a medical problem or a bad reaction happened more than once, please list each occurrence separately. If you need more space, please use another sheet of paper.

Medical problems age 18 and after	Age when problem occurred
1.
2.
3.
4.
5.
6.
7.
8.

5. Have you ever had any serious injuries, such as head injury, broken bones, burns or others that required visiting your doctor, an emergency room, or being hospitalized?

₁ Yes

₂ No → IF NO, GO TO QUESTION 6

5a. Please describe your injuries and ages at which the injuries occurred. If you need more space, please use another sheet of paper.

Description of Injury	Age at which you were injured
1.
2.
3.
4.
5.
6.
7.
8.

6. Have you ever had other surgeries or hospitalizations? Please do not include the illnesses or injuries you described in items 4 and 5 above? (Women, please do not include hospitalizations for normal deliveries)

₁ Yes

₂ No → IF NO, GO TO QUESTION 7

6a. Please describe your surgeries and hospitalizations. Please include the age at the time of the surgery or hospitalization. If you need more space, please use another sheet of paper.

Description of Surgery/Hospitalization	Age at Surgery/ Hospitalization
1.
2.
3.
4.
5.
6.
7.
8.

7. During a typical 7-day period (a week), how many times, on average, do you do the following kinds of exercise for more than 15 minutes during your leisure time? Also, for how many minutes do you usually do each kind of exercise?

		Times Per Week	Minutes Each Time
7a.	STRENUOUS EXERCISE (HEART BEATS RAPIDLY) (examples: running, jogging, soccer, squash, hockey, basketball, football, judo, roller skating, vigorous swimming, vigorous long distance bicycling)
7b.	MODERATE EXERCISE (NOT EXHAUSTING) (examples: fast walking, lifting weights, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, popular and folk dancing, gardening)
7c.	MILD EXERCISE (MINIMAL EFFORT) (examples: easy walking, yoga, archery, fishing from river bank, bowling, horseshoes, golf, snow-mobiling)

7d. If you are you currently employed, what is the activity level of your job?

₁ Not currently employed

₂ Very active-one that involves heavy lifting, digging, strenuous labor (for example, construction labor, landscaping, lumberjack)

₃ Active-one that involves walking and/or light lifting (for example, carpenter, mail delivery, janitor)

₄ Moderately active-one that combines standing and walking (for example, security guard, mechanic, nursing)

₅ Inactive-one that combines sitting and standing (for example, cashier, sales, teaching)

₆ Very inactive-one that involves mostly sitting (for example, desk job, telemarketing, truck driver)

8. In the last year, did your weight change a lot?

₁ Yes ₂ No → IF NO, GO TO QUESTION 9

8a. Did you intend to gain or lose this weight?

₁ Yes ₂ No

8b. How much weight did you gain in the last year? ______ pounds

8c. How much weight did you lose in the last year? ______ pounds

TOBACCO USE

9. Have you ever smoked cigarettes regularly, that is, as least one per day for six months or longer?

₁ Yes ₂ No → IF NO, GO TO QUESTION 10

9a. How old were you when you started smoking cigarettes regularly? Age: ______

9b. How many cigarettes would you say you smoke(d) per day?

Cigarettes per day: _________

9c. Do you currently smoke cigarettes?

₁ Yes → IF YES, GO TO QUESTION 9e ₂ No

9d. How old were you when you quit smoking cigarettes? Age: _________

9e. Between the time when you started smoking cigarettes and the time that you quit or now, was there ever a period of one year or longer when you did not smoke cigarettes?

₁ Yes ₂ No → IF NO, GO TO QUESTION 10

9f. How many years did you not smoke cigarettes?

Number of years: _________

10. Do you currently smoke cigars?

₁ Yes ₂ No

11. Do you currently chew tobacco?

₁ Yes ₂ No

12. Do you currently use snuff?

₁ Yes ₂ No

The rest of this questionnaire is about health history. For some conditions or health problems you have had, please tell us the age at which it began and whether you have had this condition or illness in the past 12 months. The clinic doctor and nurse will review your completed form with you during your clinic appointment.

Have you ever had this condition or illness?		If “YES”:		DOCTOR/NURSE USE ONLY
		How old were you when you first had this condition?	Have you had this condition in the last 12 months?
13a. Asthma	Yes No (SKIP TO 13B)	AGE: ____	Yes No	Ask about the allergens.
13b. Sudden, severe swelling of the face, mouth, and throat (Quincke's edema)	Yes No (SKIP TO 13C)	AGE: ____	Yes No	Ask about the allergens.
13c. Anaphylactic shock	Yes No (SKIP TO 13D)	AGE: ____	Yes No	Ask about the allergens.
13d. Other allergies	Yes No (SKIP TO 14a)	AGE: ____	Yes No	Ask about the allergens
13e. What other allergies have you had?				Ask about the allergens.
Skin
14a. Eczema	Yes No (SKIP TO 14B)	AGE: ____	Yes No
14b. Hives	Yes No (SKIP TO 14C)	AGE: ____	Yes No
14c. Skin rashes	Yes No (SKIP TO 14D)	AGE: ____	Yes No
14d. Skin discoloration or swelling	Yes No (SKIP TO 14E)	AGE: ____	Yes No
14e. Other skin problems	Yes No (SKIP TO 15A)	AGE: ____	Yes No
14f. What other skin problems have you had?
Head
15a. Headaches (for example, tension headaches, migraines)	Yes No (SKIP TO 16A)	AGE: ____	Yes No
Eyes
16a. Glaucoma	Yes No (SKIP TO 16B)	AGE: ____
16b. Eye infection	Yes No (SKIP TO 16C)	AGE: ____	Yes No
16c. Cataract	Yes No (SKIP TO 16D)	AGE: ____
16d. Other eye problems	Yes No (SKIP TO 17A)	AGE: ____	Yes No
16e. What other eye problems have you had?
Ears, Nose, Mouth and Throat
17a. Problems hearing	Yes No (SKIP TO 17B)	AGE: ____	Yes No
17b. Ringing in your ears	Yes No (SKIP TO 17C)	AGE: ____	Yes No
17c. Ear infections as an adult	Yes No (SKIP TO 17D)	AGE: ____	Yes No
17d. Problems with a stuffy nose or drainage from your nose to your throat.	Yes No (SKIP TO 17E)	AGE: ____	Yes No
17e. Sores in your mouth or nose	Yes No (SKIP TO 17F)	AGE: ____	Yes No
17f. Problems with dry mouth	Yes No (SKIP TO 17G)	AGE: ____	Yes No
17g. Gum disease (for example: bleeding gums, gum recession)	Yes No (SKIP TO 17H)	AGE: ____	Yes No
17h. Problems swallowing or the feeling of a lump in your throat	Yes No (SKIP TO 18A)	AGE: ____	Yes No
Neck
18a. Tenderness or pain in your neck	Yes No (SKIP TO 19A)	AGE: ____	Yes No
Digestive System
19a. Poor appetite	Yes No (SKIP TO 19B)	AGE: ____	Yes No
19b. Excessive appetite	Yes No (SKIP TO 19C)	AGE: ____	Yes No
19c. Heartburn or gastro-esophageal reflux (GER)	Yes No (SKIP TO 19D)	AGE: ____	Yes No
19d. Gastritis or ulcer	Yes No (SKIP TO 19E)	AGE: ____	Yes No
19e. Blood in bowel movements	Yes No (SKIP TO 19F)	AGE: ____	Yes No
19f. Hemorrhoids	Yes No (SKIP TO 19G)	AGE: ____	Yes No
19g. Inflammatory bowel disease, ulcerative colitis or Crohn’s disease	Yes No (SKIP TO 19H)	AGE: ____	Yes No
19h. Hepatitis	Yes No (SKIP TO 19I)	AGE: ____	Yes No
19i. Cirrhosis	Yes No (SKIP TO 19J)	AGE: ____	Yes No
19j. Gallbladder problems	Yes No (SKIP TO 19K)	AGE: ____	Yes No
19k. Recurring or persistent nausea or vomiting	Yes No (SKIP TO 19L)	AGE: ____	Yes No
19l. Recurring or persistent diarrhea	Yes No (SKIP TO 19M)	AGE: ____	Yes No
19m. Recurring or persistent constipation	Yes No (SKIP TO 19N)	AGE: ____	Yes No
19n. Chronic or persistent bloating	Yes No (SKIP TO 19O)	AGE: ____	Yes No
19o. Other problems with digestive system	Yes No (SKIP TO 19Q)	AGE: ____	Yes No
19p. What other problems have you had with your digestive system?
19q. High cholesterol	Yes No (SKIP TO 19R)	AGE: ____	Yes No
19r. High triglycerides	Yes No (SKIP TO 20A)	AGE: ____	Yes No
Chest: Heart and Lungs
20a. Chronic cough	Yes No (SKIP TO 20B)	AGE: ____	Yes No
20b. Chronic bronchitis	Yes No (SKIP TO 20C)	AGE: ____	Yes No
20c. Chronic obstructive pulmonary disease (COPD) or emphysema	Yes No (SKIP TO 20D)	AGE: ____	Yes No
20d. Shortness of breath when inactive (sitting or in bed)	Yes No (SKIP TO 20E)	AGE: ____	Yes No
20e. Shortness of breath when you walk, run, or climb stairs	Yes No (SKIP TO 20F)	AGE: ____	Yes No
20f. Fluid in your lungs	Yes No (SKIP TO 20G)	AGE: ____	Yes No
20g. Pneumonia	Yes No (SKIP TO 20H)	AGE: ____	Yes No
20h. Wheezing	Yes No (SKIP TO 20I)	AGE: ____	Yes No
20i. Chest pain	Yes No (SKIP TO 20J)	AGE: ____	Yes No
20j. High blood pressure	Yes No (SKIP TO 20K)	AGE: ____	Yes No
20k. Low blood pressure	Yes No (SKIP TO 20L)	AGE: ____	Yes No
20l. Heart problems or irregular heart beat (arrhythmia)	Yes No (SKIP TO 20M)	AGE: ____	Yes No
20m. Problems with your arteries	Yes No (SKIP TO 20N)	AGE: ____	Yes No
20n. Swelling of your legs	Yes No (SKIP TO 20O)	AGE: ____	Yes No
20o. Feet or hands get cold very easily	Yes No (SKIP TO 20P)	AGE: ____	Yes No
20p. Other lung,heart or vascular problems?	Yes No (SKIP TO 21A)	AGE: ____	Yes No
20q. What other lung, heart or vascular problems have you had?
Urinary Tract
21a. Bladder or kidney infection, or urinary tract infection (UTI)	Yes No (SKIP TO 21B)	AGE: ____	Yes No
21b. Kidney stones	Yes No (SKIP TO 21C)	AGE: ____	Yes No
21c. Frequent need to urinate (pee)	Yes No (SKIP TO 21D)	AGE: ____	Yes No
21d. Problems with starting to urinate (pee)	Yes No (SKIP TO 21E)	AGE: ____	Yes No
21e. Burning sensation or pain when urinating (peeing)	Yes No (SKIP TO 21F)	AGE: ____	Yes No
21f. Other kidney or urinary problems	Yes No (SKIP TO 21H)	AGE: ____	Yes No
21g. What other kidney or urinary problems have you had?
21h. How many times per night, on average, do you get up to go to the bathroom? ___ times
Nervous System
22a. Dizziness or vertigo (“head spinning”)	Yes No (SKIP TO 22B)	AGE: ____	Yes No
22b. Feeling faint or fainting	Yes No (SKIP TO 22C)	AGE: ____	Yes No
22c. Poor balance	Yes No (SKIP TO 22D)	AGE: ____	Yes No
22d. Poor coordination	Yes No (SKIP TO 22E)	AGE: ____	Yes No
22e. Numbness or tingling on face, trunk, arms or legs	Yes No (SKIP TO 22F)	AGE: ____	Yes No
22f. Loss of consciousness (other than fainting)	Yes No (SKIP TO 22G)	AGE: ____	Yes No
22g. Seizures	Yes No (SKIP TO 22H)	AGE: ____	Yes No
22h. Encephalitis	Yes No (SKIP TO 22I)	AGE: ____	Yes No
22i. Meningitis	Yes No (SKIP TO 22J)	AGE: ____	Yes No
22j. Other neurological problems	Yes No (SKIP TO 23A)	AGE: ____	Yes No
22k. What other neurological problems have you had?
Musculo-skeletal System
23a. Pain in muscles, tendons or joints	Yes No (SKIP TO 23B)	AGE: ____	Yes No
23b. Stiffness in joints or back	Yes No (SKIP TO 23C)	AGE: ____	Yes No
23c. Carpal tunnel syndrome or other tendon problems	Yes No (SKIP TO 23D)	AGE: ____	Yes No
23d. Bone problems (including osteopenia and osteoporosis)	Yes No (SKIP TO 23E)	AGE: ____	Yes No
23e. Muscle weakness	Yes No (SKIP TO 23F)	AGE: ____	Yes No
23f. Systemic Lupus Erythematosus	Yes No (SKIP TO 23G)	AGE: ____	Yes No
23g. Rheumatoid Arthritis	Yes No (SKIP TO 23H)	AGE: ____	Yes No
23h. Other arthritis	Yes No (SKIP TO 23J)	AGE: ____	Yes No
23i. What other arthritis have you had?
23j. Fibromyalgia	Yes No (SKIP TO 24A)	AGE: ____	Yes No
Endocrine System
24a. Diabetes or high blood sugar	Yes No (SKIP TO 24B)	AGE: ____	Yes No
24b. Problems with your thyroid gland	Yes No (SKIP TO 24C)	AGE: ____	Yes No
24c. Other endocrine problems	Yes No (SKIP TO 25A)	AGE: ____	Yes No
24d. What other endocrine problems have you had?
Blood
25a. Anemia, low hemoglobin, “thin blood,” or low number of red blood cells	Yes No (SKIP TO 25B)	AGE: ____	Yes No
25b. Easy bruising or bleeding	Yes No (SKIP TO 25C)	AGE: ___	Yes No
25c. Very low white blood cell count	Yes No (SKIP TO 25D)	AGE: ___	Yes No
25d. Very high white blood cell count	Yes No (SKIP TO 25E)	AGE: ___	Yes No
25e. Leukemia	Yes No (SKIP TO 25F)	AGE: ____	Yes No
25f. Hodgkin's Lymphoma	Yes No (SKIP TO 25G)	AGE: ____	Yes No
25g. Lymphoma (non-Hodgkin’s)	Yes No (SKIP TO 25H)	AGE: ____	Yes No
25h. Swollen lymph nodes (for example, around your neck, or in your groin, or armpits or other places on your body)	Yes No (SKIP TO 25I)	AGE: ____	Yes No
25i. Infectious mono-nucleosis (also called “Mono”)	Yes No (SKIP TO 25J)	AGE: ____	Yes No
25j. Blood diseases (such as sickle cell anemia, thalassemia or hemophilia)	Yes No (SKIP TO 25L)	AGE: ____	Yes No
25k. What blood diseases have you had? (Check all that apply.) Sickle cell anemia Thalassemia Hemophilia Other, please specify: Age started:
25l. Have you ever had blood transfusions?	Yes No (SKIP TO 26A)	AGE: ____		For what reason
Sexual History
26a. Low sexual drive/desire	Yes No (SKIP TO 26B)	AGE: ____	Yes No
26b. Pain during sexual intercourse	Yes No (SKIP TO 27A)	AGE: ____	Yes No
FEMALES, PLEASE SKIP TO 27a. Also, remember to fill out the gynecological questionnaire.
27a. Problems with prostate (MALES ONLY)	Yes No (SKIP TO 28A)	AGE: ____	Yes No

28a. Are there any other particular problems or concerns related to your health that you would like to mention?

₁ Yes → GO TO QUESTION 28B

₂ No → GO TO NEXT PAGE

28b. Please describe the problems or concerns below. Use more pages if necessary.

Other diseases (or health problems/ concerns)	How old were you when this problem began?	Do you still have this problem?	DOCTOR/NURSE USE ONLY
1.	AGE: ______	Yes No
2.	AGE: ______	Yes No
3.	AGE: ______	Yes No
4.	AGE: ______	Yes No
5.	AGE: ______	Yes No
6.	AGE: ______	Yes No

Additional notes to questions

If you wish to explain more about a condition or illness that you had, please use the space provided below (Remember to enter the number of the question to which your explanation applies).

21