NIS Section D Health Proxy Child
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1 NIS Section D Health Proxy Child Data Set Name FINAL.D_PROXY Observations 810 Member Type DATA Variables 193 Engine V9 Indexes 0 Created Thursday, March 02, :29:50 PM Observation Length 1952 Last Modified Thursday, March 02, :29:50 PM Deleted Observations 0 Protection Compressed NO Data Set Type Sorted NO Label Data Representation WINDOWS_32 Encoding wlatin1 Western (Windows) Engine/Host Dependent Information Data Set Page Size Number of Data Set Pages 103 First Data Page 2 Max Obs per Page 8 Obs in First Data Page 4 Number of Data Set Repairs 0 File Name C:\NIS\Final\Data\d_proxy.sas7bdat Release Created M2 Host Created XP_PRO 1 PU_ID Char 8 RESPONDENT ID 2 D1 Num 8 HEALTH CONDITION 3 D2 Char 10 COMPARE HEALTH A YEAR AGO 4 D3 Num 8 COMPARE HEALTH BEFORE COMING TO US 5 D4 Num 8 HAVE HIGH BLOOD PRESSURE 6 D5 Num 8 HOW LONG HAD HIGH BLOOD PRESSURE 7 D5A Num 8 D5UNIT 8 D6 Num 8 LIMIT ACTIVITY BY HIGH BLOOD PRESSURE 9 D7 Num 8 MEDICATION TO LOWER BLOOD PRESSURE 10 D8 Num 8 HAVE DIABETES 11 D9 Num 8 HOW LONG HAD DIABETES 12 D9A Num 8 D9UNIT 13 D10 Num 8 LIMIT ACTIVITY BY DIABETES 14 D11 Num 8 SWALLOW MEDICATION FOR DIABETES 15 D12 Num 8 USE INSULIN FOR DIABETES 16 D13 Num 8 HAVE CANCER 17 D14 Num 8 HOW LONG HAD CANCER 18 D14A Num 8 D14UNIT 19 D15 Num 8 LIMIT ACTIVITY CANCER 20 D16 Num 8 TREATMENT FOR CANCER 21 D17 Num 8 CHEMOTHERAPY OR MEDICATION D17 22 D17A Num 8 SURGERY OR BIOPSY D17 Contents D-proxy 1
2 23 D17B Num 8 RADIATION OR X-RAY D17 24 D17C Num 8 MEDICATIONS OR TREATMENT FOR SYMPTOMS D1 25 D17E Num 8 NONE D17 26 D17F Num 8 OTHER D17 27 D17G Char 80 SPECIFY D17F 28 D18 Num 8 YEAR MOST RECENT CANCER DIAGNOSED 29 D18A Num 8 MONTH CANCER DIAGNOSED 30 D18B Num 8 STILL HAVE CANCER 31 D19 Num 8 HAVE CHRONIC LUNG DISEASE 32 D20 Num 8 HOW LONG HAD CHRONIC LUNG DISEASE 33 D20A Num 8 D20UNIT 34 D21 Num 8 LIMIT ACTIVITY CHRONIC LUNG DISESASE 35 D22 Num 8 TAKE MEDICATION FOR LUNG CONDITION 36 D23 Num 8 LUNG CONDICTION LIMIT USUAL ACTIVITY 37 D24 Num 8 HAVE HEART PROBLEM 38 D25 Num 8 LIMIT ACTIVITY HEART PROBLEM 39 D26 Num 8 TAKE MEDICATION HEART PROBLEM 40 D27 Num 8 EVER HAD HEART ATTACK 41 D28 Num 8 YEAR FIRST HEART ATTACK 42 D28A Num 8 MONTH FIRST HEART ATTACK 43 D29 Num 8 NOW TAKE MEDICATION HEART ATTACK 44 D30 Num 8 HAD MORE THAN ONE HEART ATTACK 45 D31 Num 8 YEAR MOST RECENT HEART ATTACK 46 D31A Num 8 MONTH MOST RECENT HEART ATTACK 47 D32 Num 8 HAD ANGINA 48 D33 Num 8 TAKE MEDICATION BECAUSE OF ANGINA 49 D34 Num 8 LIMIT ACTIVITY ANGINA 50 D35 Num 8 HAVE CONGESTIVE HEART FAILURE 51 D36 Num 8 ADMITTED TO HOSPITAL OVERNIGHT DUE TO D3 52 D37 Num 8 IN US D35 53 D37Amo Num 8 IN WHAT CTRY ADMT TO HOSPITAL DUE TO D35-modif 54 D38 Num 8 TAKE MEDICATION FOR CONGESTIVE HEART FAI 55 D39 Num 8 HAD TEST OF HEART WITH TUBES 56 D40 Num 8 IN US HAD TEST OF HEART WITH TUBES 57 D40Amo Num 8 IN WHAT COUNTRY HAD TEST OF HEART WITH T-modif 58 D41 Num 8 HAD SURGERY ON HEART 59 D42 Num 8 IN US HAD SURGERY ON HEART 60 D42Amo Num 8 IN WHAT COUNTRY HAD SURGERY ON HEART-modif 61 D43 Num 8 HAD A STROKE 62 D44 Num 8 SEEN DOCTOR BECAUSE OF STROKE 63 D45 Num 8 IN US SEEN DOCTOR 64 D45Amo Num 8 IN WHAT COUNTRY SEEN DOCTOR-modif 65 D46 Num 8 HAD MORE THAN ONE STROKE 66 D47 Num 8 HAVE REMAINING PROBLEMS DUE TO STROKE 67 D48 Num 8 TAKE MEDICATION DUE TO STROKE 68 D49 Num 8 YEAR MOST RECENT STROKE 69 D49A Num 8 MONTH MOST RECENT STROKE Contents D-proxy 2
3 70 D50 Num 8 HAD EMOTIONAL PROBLEM 71 D51 Num 8 GET PSYCHIATRIC TREATMENT 72 D52 Num 8 HOW LONG HAD PSYCHIATRIC TREATMENT 73 D52A Num 8 UNITD52 74 D53 Num 8 LIMIT ACTIVITY PSYCHIATRIC CONDITION 75 D54 Num 8 TAKE TRANQUILIZERS 76 D55 Num 8 HAD ARTHRITIS 77 D56 Num 8 HOW LONG HAD ARTHRITIS 78 D56A Num 8 UNITD56 79 D57 Num 8 LIMIT ACTIVITY ARTHRITIS 80 D58 Num 8 TAKE MEDICATION ARTHRITIS 81 D59 Num 8 HAD ASTHMA 82 D60 Num 8 YEAR ASTHMA 83 D60A Num 8 UNITD60 84 D61 Num 8 CURRENTLY HAVE ASTHMA 85 D62 Num 8 LIMIT ACTIVITY ASTHMA 86 D63 Num 8 WEAR GLASSES 87 D64 Num 8 HOW IS EYESIGHT 88 D65 Num 8 WEAR HEARING AID 89 D66 Num 8 HOW IS HEARING 90 D67 Num 8 TROUBLED WITH PAIN 91 D68 Num 8 HOW BAD IS PAIN 92 D69 Num 8 PAIN MAKES ACTIVITY DIFFICULT 93 D70 Num 8 CHECK BREASTS MONTHLY 94 D71 Num 8 HAVE MAMMOGRAM 95 D72 Num 8 HAVE PAP SMEAR 96 D73 Num 8 HAD EXAMINATION OF PROSTATE 97 D74 Num 8 EVER SMOKED CIGARETTES 98 D75 Num 8 SMOKE CIGARETTES NOW 99 D76 Num 8 HOW MANY CIGARETTES SMOKE IN A DAY 100 D76A Num 8 UNITD D77 Num 8 HOW OLD STARTED SMOKING 102 D77A Num 8 YEARSD D78 Num 8 HOW MANY CIGS A DAY WHEN SMOMED MOST 104 D78A Num 8 UNITD D79 Num 8 HOW OLD WHEN SMOKING MOST 106 D79A Num 8 YEARD D80 Num 8 HOW MANY YEARS STOP SMOKING 108 D80A Num 8 YEARSD D81 Num 8 DRINK ALCOHOLIC BEVERAGES 110 D82 Num 8 HOW MANY DAYS HAD ALCOHOL LAST 3 MOS 111 D83 Num 8 HOW MANY DAYS HAD FOUR OR MORE DRINKS 112 D84 Num 8 EVER DRUNK ALCOHOLIC BEVERAGES 113 D85 Num 8 EVER FELT SHOULD CUT DOWN ON DRINKING 114 D86 Num 8 HOW OFTEN LIGHT PHYSICAL ACTIVITY 115 D86A Num 8 UNITD D86B Char 30 SPECIFY D86A Contents D-proxy 3
4 117 D87 Num 8 HOW OFTEN VIGOROUS PHYSICAL ACTIVITY 118 D87A Num 8 UNITD D87B Char 30 SPECIFY D87A 120 D88 Num 8 FELT SAD OR DEPRESSED 121 D89 Num 8 TWO WEEK PERIOD WHEN FEELINGS WERE WORST 122 D90 Num 8 TWO WEEK PERIOD IN US 123 D90Amo Num 8 IN WHAT COUNTRY FELT SAD-modif 124 D91 Num 8 FEEL THIS WAY EVERY DAY 125 D92 Num 8 LOSE INTEREST 126 D93 Num 8 FEEL MORE TIRED 127 D94 Num 8 LOSE APPETITE 128 D95 Num 8 HAVE TROUBLE FALLING ASLEEP 129 D96 Num 8 D95 HAPPEN HOW OFTEN 130 D97 Num 8 HAVE TROUBLE CONCENTRATING 131 D98 Num 8 FEEL DOWN ON SELF 132 D99 Num 8 THINK ABOUT DEATH 133 D100 Num 8 EVER FELT SAD ABOUT IMMIGRATION PROCESS 134 D101 Num 8 DID PERIOD FELT SAD LAST TWO WEEKS 135 D102 Num 8 HAVE PHYSICAL CONDITION THAT LIMIT WORK 136 D103 Num 8 CONDITION KEEP FROM DOING SOME WORK 137 D104 Num 8 HEALTH WHILE GROWING UP 138 D105 Num 8 MISS SCHOOL DUE TO HEALTH 139 D106mo Num 8 MOST SERIOUS HEALTH CONDIT CAUSE D105-modif 140 D107 Num 8 SPORTS RESTRICTED FOR THREE MONTHS 141 D108mo Num 8 MOST SERIOUS HEALTH CONDIT CAUSE D107-modif 142 D109 Num 8 HOW OLD HAD HEALTH CONDIT D D110 Num 8 CONFINE TO BED DUE TO HEALTH 144 D111mo Num 8 MOST SERIOUS HEALTH CONDIT CAUSE D110-modif 145 D112 Num 8 COMPARE CURRENT HEALTH TO PEOPLE IN HOME 146 D113 Num 8 HOW OFTEN SEE DOCTOR BEFORE TO US 147 D114 Num 8 COMPARE SIMILARITY IN DIET 148 D115 Num 8 RARELY ATE BEFORE US 149 D116 Char 80 MOST IMPORTANT THING EAT A LOT NOW 150 D117 Num 8 ATE REGULARLY BEFORE US 151 D118 Char 80 MOST IMPORTANT THING RARELY EAT NOW 152 D119 Char 80 USUAL SOURCE OF HEALTH CARE IN US 153 D120 Num 8 CHANGE USUAL SOURCE OF HEALTH CARE 154 D121 Char 80 USUAL SOURCE OF HEALTH CARE BEFORE PERMA 155 D122_1 Num 8 EVER RECEIVED ACCUPUNCTURE 156 D123_1 Num 8 RECEIVE D122 IN NON US COUNTRY 157 D124_1 Num 8 RECEIVE D122 IN US 158 D122_2 Num 8 EVER RECEIVED CHIRO CARE 159 D123_2 Num 8 RECEIVE D122 IN NON US COUNTRY 160 D124_2 Num 8 RECEIVE D122 IN US 161 D122_3 Num 8 EVER RECEIVED MASSAGE THERAPY 162 D123_3 Num 8 RECEIVE D122 IN NON US COUNTRY 163 D124_3 Num 8 RECEIVE D122 IN US 164 D122_4 Num 8 EVER RECEIVED BIOFEEDBACK TRAINING Contents D-proxy 4
5 165 D123_4 Num 8 RECEIVE D122 IN NON US COUNTRY 166 D124_4 Num 8 RECEIVE D122 IN US 167 D122_5 Num 8 EVER RECEIVED MEDITATION IMAGERY 168 D123_5 Num 8 RECEIVE D122 IN NON US COUNTRY 169 D124_5 Num 8 RECEIVE D122 IN US 170 D122_6 Num 8 EVER RECEIVED HOMEOPATHIC TREATMENT 171 D123_6 Num 8 RECEIVE D122 IN NON US COUNTRY 172 D124_6 Num 8 RECEIVE D122 IN US 173 D122_7 Num 8 EVER RECEIVED SPIRITUAL HEALING OR PRAYE 174 D123_7 Num 8 RECEIVE D122 IN NON US COUNTRY 175 D124_7 Num 8 RECEIVE D122 IN US 176 D122_8 Num 8 EVER RECEIVED HYPNOSIS 177 D123_8 Num 8 RECEIVE D122 IN NON US COUNTRY 178 D124_8 Num 8 RECEIVE D122 IN US 179 D122_9 Num 8 EVER RECEIVED TRAD MEDICINE 180 D123_9 Num 8 RECEIVE D122 IN NON US COUNTRY 181 D124_9 Num 8 RECEIVE D122 IN US 182 D125 Num 8 EVER TESTED FOR TB 183 D126 Num 8 TEST POSITIVE FOR TB 184 D127 Num 8 RECEIVE TREATMENT FOR TB 185 D128 Num 8 COMPLETE TREATMENT FOR TB 186 D129mo Num 8 HOW MUCH WEIGH-modif 187 D129Amo Num 8 UNIT WEIGH-modif 188 D130mo Num 8 HOW TALL-modif 189 D130Amo Num 8 UNIT TALL-modif 190 D130Bmo Num 8 HOW TALL METERS AND FEET-modif 191 D130Cmo Num 8 UNIT CENTM AND INCHES-modif 192 DTIMEEND Num 8 END SECTION D ELAPSED TIME 193 NISWGTSAMP1 Num 8 Sampling Weight Contents D-proxy 5
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ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
Placer Private Physicians: Patient Health Questionnaire [2]
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Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
To: Our Medicare Patients. Subject: Your Welcome to Medicare Exam
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Top Tier. Medical Breast Specialist, P.C.
Karen S. Barbosa, D.O. Board Certified, Fellowship Trained Breast Surgeon Top Tier Medical Breast Specialist, P.C. 80 Maple Avenue Smithtown, NY 11787 Office: 631.870.8721 Fax: 631.870.8722 Office Visit
PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE. Date of Appt: / / Name: Date of Birth: / / Last First Middle
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MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
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Single Married Divorced Widowed Male Female
Annual Physical Form General Information Name Birth Date Phone Email Address Street Address City State Zip Marital Status Gender Single Married Divorced Widowed Male Female Employment Information Position
COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
What brings you in today? What do you prefer to be called (nickname)? Please list all of your medical conditions. 1. 5. 2. 6. 3. 7. 4. 8. What surgical or medical procedures have you had in the past? 1.
MEDICARE ANNUAL WELLNESS VISIT
MEDICARE ANNUAL WELLNESS VISIT FAMILY MEDICINE CENTERS OF SOUTH CAROLINA, LLC Springwood Lake Midtown Woodhill Saluda Pointe Lake Murray Name: Ethnic Background: Race: Age: Sex: Marital Status: PLEASE
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DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM
Name: MR#: Date: DEEP BRAIN STIMULATION SURGICAL CANDIDACY EVALUATION FORM Referring Physician s Name: Primary Care Provider s Name: 1. What was/were your first movement disorder symptoms? What did you
NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician
Medical Questionnaire
MEDICIS Health Testing Center Avenue de Tervueren 236 115 Bruxelles Tel : 2/762.5.44 Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address :...... Phone (private) : Office :. Date of
Standard Medicare and Managed Medicare plans pay for diabetes education.
614-447-9495, ext. 1 You are scheduled to attend a series of four diabetes education classes. If you are not able to attend the class series, we ask that you cancel your appointment at least 48 working
New Patient Medical History Intake Form
New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd
Medicare Annual Wellness Visit HEALTH RISK ASSESSMENT
Patient Name: Date of Birth: GENERAL HEALTH 1. How is your overall health? Excellent Good Fair Poor 2. How many different prescriptions are you taking? 0-3 4-6 7-10 10+ 3. Do you take all of your mediations
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist
Lifestyle/Readiness for Change Assessment
Lifestyle/Readiness for Change Assessment This form asks you a variety of questions about your lifestyle habits. This questionnaire should take about 10 minutes. Fill in the information requested, or place
SELF-REPORTING HEALTH HISTORY
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SECTION I. Personal Health Assessment. Risk Levels for Specific Health Conditions. OVERALL HEALTH RISK LEVEL Moderate. CANCER High.
DATE COMPLETED: 02/12/2007 USER: 0000128 GENDER: Female SECTION I Personal Health Assessment OVERALL HEALTH RISK LEVEL Risk Levels for Specific Health Conditions CANCER High DIABETES Low HEART DISEASE
Client Name: Date: Birthdate: Age: Gender: F M Address: Phone # home: cell: work:
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Polysomnography Patient Questionnaire
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Here are a few ideas to help you cope and get through this learning period:
Coping with Diabetes When you have diabetes you may feel unwell and have to deal with the fact that you have a life long disease. You also have to learn about taking care of yourself. You play an active