Adapted from Framingham Heart Study 2013
Medication Questionnaire
Self-administered
| Check if NO medication taken and leave the page BLANK |
This questionnaire refers to medication recommended to you by your doctor or health care provider.
For the question below, please check YES or NO
| YES | NO | Did you ever forget to take your medicine? |
| YES | NO | Are you careless at times about taking your medicine? |
| YES | NO | When you feel better do you stop taking your medicine? |
| YES | NO | Sometimes if you feel worse when you take the medicine, do you stop taking it? |
| How often do you forget to take your medicine? (Circle only ONE) | |
| 1. | Never |
| 2. | More than once per week |
| 3 | Once per week |
| 4. | More than once per month |
| 5. | Once per month |
| 6. | Less than once per month. |
Medical History—Medications
| |__| | Do you take aspirin regularly? (0=No, 1=Yes, 9=Unknown) | ||
| If yes, fill | |__|__| | Number of aspirins taken regularly (99=Unknown) | |
| |__| | Frequency per (1=Day, 2=Week 3=Month, 4=Year, 9=Unknown) | ||
| |__|__|__| | Usual dose (write in mgs, 999=Unknown) | Examples: 081=baby,160=half dose, 250= like in Excedrin, 325=usual dose, 500=extra strength | |
Since your last exam(0=No, 1=Yes, 9=Unknown) |
|
| |__| |
Have you been told by doctor you have high blood pressure or hypertension? |
| |__| |
Have you taken medication for high blood pressure or hypertension? |
| |__| |
Have you been told by doctor you have high blood cholesterol or high triglycerides? |
| |__| |
Have you taken medication for high blood cholesterol or high triglycerides? |
| |__| |
Have you been told by doctor you have high blood sugar or diabetes? |
| |__| |
Have you taken medication for high blood sugar or diabetes? |
| |__| |
Have you taken medication for cardiovascular disease? (For example angina/chest pain, heart failure, atrial fibrillation/heart rhythm abnormality, stroke, leg pain when walking, peripheral artery disease) |
Medical History – Prescription and Non-Prescription Medications
Copy the name of medicine, the strength including units, and the total number of doses per day/week/month/year. Include vitamins and minerals.
| |__| | Medication bag with medications or bottles/packs brought to exam? (0=No 1=Yes) | **List medications taken regularly in past month/ongoing medications** Code ASPIRIN ONLY on screen MD02. |
| £ | Check if NO medication taken |
| Medication Name(Print first 20 letters) | Strength(Include mg, IU, etc.) | Route1= oral, 2=topical, 3=injection,4=inhaled,
5=drops,6=nasal 88=other |
Number per(circle one) | PRN 0=no, 1=yes, 9=Unk. | Check if OTC med | ||||||||||||||||||||||
| # | day/week/month/year1 / 2 / 3 / 4 | ||||||||||||||||||||||||||
| 100 | mg | 1 | 1 | D W M Y | 0 | £ | |||||||||||||||||||||
| EXAMPLE: | S | A | M | P | L | E | D | R | U | G | N | A | M | E | |||||||||||||
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Medical History–Female Reproductive History Part 1
| |__| | Since your last exam have you taken or used birth control pills, shots, or hormone implants for birth control or medical indications (not post menopausal hormone replacement)?(0=no, 1=yes, now, 2=yes, not now, 9=Unknown.) | |||
| |__|
If yes,
fill
|
Have you been pregnant since last exam? (0=No, 1=Yes, 9=Unknown) | |||
| |__|__| | Number of pregnancies? | fill in number | ||
| |__|__| | Number of live births? | |||
| |__| | During any of these pregnancies, were you told you had high blood pressure or hypertension? | 0=No1=Yes
9=Unknown |
||
| |__| | During any of these pregnancies, were you told you had eclampsia, pre-eclampsia (toxemia)? | |||
| |__| | During any of these pregnancies, were you told you had high blood sugar or diabetes? | |||
Medical History–Female Reproductive History Part 2
| What is the best way to describe your periods? Check the BEST answer – only one | |||
| Not stopped | |||
| Periods stopped due to pregnancy, breastfeeding, or hormonal contraceptive (for example: depo-provera, progestin releasing IUD, extended release birth control pill) | |||
| Periods stopped due to low body weight, heavy exercise, or due to medication or health condition such as thyroid disease, pituitary tumor, hormone imbalance, stress, | |||
| Write in cause | ______________________________________________________ | ||
| Periods stopped for less than 1 year (perimenopausal) | |||
| |__|__| | Number of months since last period 99=Unknown | ||
| Periods stopped for 1 year or more | |||
| Periods stopped, but now have periods induced by hormones. | |||
| |__|__| | Number months stopped before hormones started. 99=Unknown | ||
| |__|__|*|__|__|*|__|__|__|__| month day year | When was the first day of your last menstrual period? 99/99/9999=Unknown88/88/8888= periods stopped for more than 1 year or using postmenopausal hormonesIf periods stopped due to pregnancy, breastfeeding, hormonal contraception or health condition code date of last menstrual period | |
| |__|__| | Age when periods stopped (00=not stopped, 99=Unknown)If periods now induced by hormones, code age when periods naturally stopped. If periods stopped due to pregnancy, breastfeeding, or hormonal contraception code as 0=not stopped | |
| |__| | Was your menopause natural or the result of surgery, chemotherapy, or radiation?(0=still menstruating, 1=natural, 2=surgical, 3=chemo/radiation, 4=other, 9=Unknown)If periods stopped due to pregnancy, breast feeding, or hormonal contraception code as 0=still menstruating | |
CURHAN Medical History Protocol, March 9, 2016