CURHAN Base Protocol Medical History Questionnaire

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
D W M Y £
D W M Y £
D W M Y £
D W M Y £
D W M Y £
D W M Y £
D W M Y £
D W M Y £
D W M Y £
D W M Y £

 

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

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About 陈馨雨

2014级本科生
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