Re-Screening Medical History Questionnaire

Transcription

1 Building Trades National Medical Screening Program Re-Screening Medical History Questionnaire Name: Address: _ City: _State: Zip Phone Number (include Area Code): Social Security # Date of Birth If female, are you or could you be pregnant? Medical History Physician Name: Address: _ City: State Zip Physician Phone (include Area Code) Page 1 of 6

2 I. Personal History A. In the past three years, or since your last examination, have you been told by a doctor that you have any of the following cancers: Leukemia Acute myelogenous leukemia Chronic myelogenous leukemia Acute lymphocytic leukemia Chronic lymphocytic leukemia Multiple Myeloma Hodgkin s Disease n-hodgkin s Lymphoma Bone Cancer Lung Cancer Thyroid cancer Kidney Cancer Cancer of the ureters Bladder cancer Brain Cancer Breast cancer Esophagus cancer Stomach cancer Colon or other Intestinal cancer Pancreatic cancer Liver cancer Cancer of Gall Bladder or Bile Ducts Cancer of the mouth, head or neck Pharyngeal cancer Salivary gland or parotid gland cancer Other type, list if possible: Ovarian cancer Uterine cancer Cervical cancer Testicular cancer Prostate cancer Other cancer, list name: Page 2 of 6

3 Medication History Please list your present medications: 1. In the past three years, have you been treated in a hospital? If so, for what condition(s)? 2. In the past three years, have you been diagnosed with any new medical conditions? If so, which conditions? 3. In the past three years, or since your last exam, have you ever had any of the following: Attacks of bronchitis? Pneumonia (including bronchopneumonia)? Hay fever? Chronic bronchitis? Do you still have it? Page 3 of 6

4 Emphysema? Do you still have it? Asthma? Do you still have it? Chest injuries? If YES, please specify: Any other chest illnesses? If YES, please specify: When did you last have your chest x-rayed? Where did you last have your chest x-rayed? What was the outcome? Cough If you get a cold, does it usually (i.e. more than half the time) go to your chest? During the past three years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed? Do you usually have a cough? If YES: Do you usually cough as much as two times a day 4 or more days out of the week? Do you usually cough at all on getting up or first thing in the morning? Do you usually cough at all during the rest of the day or at night? If YES to any of the above: Do you usually cough like this on most days for 3 consecutive months or more during the year? If YES: For how many years have you had the cough? Years Page 4 of 6

5 Phlegm a. Do you usually bring up phlegm from your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose Count swallowed phlegm.) b. If YES: Do you usually bring up phlegm as much as twice a day 4 or more days out of the week? Do you usually bring up phlegm at all on getting up or first thing in the morning? Do you usually bring up phlegm at all during the rest of the day or at night? c. If YES to any of the above: d. Do you bring up phlegm like this on most days for 3 consecutive months or more during the year? Have you had periods or episodes of increased cough and phlegm lasting for 3 weeks or more each year? If YES: How long have you had at least one such episode per year? Years Does your chest ever sound wheezy or whistling: When you have a cold? Occasionally apart from colds? Most days or nights? If YES to any of these, how many years has this been present? Years In the past three years, have you ever had an attack of wheezing that has made you feel short of breath? If YES, How old were you when you had your first such attack? Years Have you had 2 or more such episodes? Have you ever required medicine for these episodes? Page 5 of 6

6 Breathlessness Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill? Do you have to walk slower than people of your age because of breathlessness? Do you ever have to stop for breath when walking at your own pace on the level? Do you ever have to stop for breath after walking 100 yards (or after a few minutes) on the level? Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs? A. Cigarette Smoking Have you ever smoked cigarettes? (NO means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.) Do you now smoke cigarettes (as of one month ago)? If YES to either of the above questions: How old were you when you first started regular cigarette smoking? If you have stopped, how old were you when you stopped completely? How many cigarettes did you or do you smoke per day? On average of the entire time you smoked, how many cigarettes did you or do you smoke per day? Do you or did you inhale the cigarette smoke? Age # Don t Know Don t Know t at all Slightly Moderately Deeply Please sign here to verify this is your history: Examining Doctor please initial here to verify that you have reviewed this history: Page 6 of 6