13 / PLEASE USE A BALL-POINT PEN WHEN COMPLETING THIS QUESTIONNAIRE. IT IMPROVES THE QUALITY OF OUR DATA.

Transcription

1 Date of birth: 13 PLEASE USE A BALL-POINT PEN WHEN COMPLETING THIS QUESTIONNAIRE. IT IMPROVES THE QUALITY OF OUR DATA. 1. We use DATE OF BIRTH to verify the identity of the person providing information. Is the DOB above correct? IF NO, what is your correct date of birth? WITHIN THE PAST 2 YEARS, have you been NEWLY DIAGNOSED with any of the following illnesses or had any of the following procedures? Please answer NO or YES on each line. IF YES, indicate the date (monthyear) of the diagnosis or the procedure. K DIAGNOSIS OR PROCEDURE NO or YES IF YES, PROVIDE MOYR IN BOXES BELOW a. Acute coronary syndromeunstable angina MOYR of diagnosis: b. Angina pectoris MOYR of diagnosis: If YES, confirmed by: angiogramcardiac cath? stress test? c. Myocardial infarction (heart attack) MOYR of diagnosis: d. Coronary angioplasty (PTCA or PCI) or stent MOYR of procedure: e. Coronary bypass surgery (CABG) MOYR of procedure: f. Congestive heart failure MOYR of diagnosis: g. Atrial fibrillation MOYR of diagnosis: h. Intermittent claudication MOYR of diagnosis: i. Peripheral artery disease (not varicose veins) MOYR of diagnosis: j. Pulmonary embolism (PE) MOYR of diagnosis: k. Deep vein thrombosis (DVT) MOYR of diagnosis: l. Stroke MOYR of diagnosis: m. TIA (transient ischemic attack) MOYR of diagnosis: n. Carotid artery surgery (endarterectomy) MOYR of surgery: o. Melanoma MOYR of diagnosis: p. n-melanoma skin cancer MOYR of diagnosis: What type? basal cell squamous cell unknown type q. Breast cancer MOYR of diagnosis: r. Lung cancer MOYR of diagnosis: s. Colon cancer MOYR of diagnosis: t. Other cancer (not including any of the above cancers) MOYR of diagnosis: SITE: u. Colon polyp MOYR of diagnosis: v. Diabetes mellitus (NEWLY diagnosed) MOYR of diagnosis: Office use: Page 1 (OVER)

2 13 2. (continued) NEWLY DIAGNOSED IN LAST 2 YEARS? IF YES, PROVIDE DATE (MOYR) IN BOXES BELOW w. Migraine headaches (NEWLY diagnosed) MOYR of diagnosis: x. Other headaches (NEWLY diagnosed) y. Parkinson's disease z. Elevated cholesterol (NEW dx by a clinician) aa. Hypertension (NEW dx by a clinician) bb. Osteoarthritis (NEWLY diagnosed) cc. Osteoporosis (NEWLY diagnosed) dd. Fracture due to osteoporosis ee. Joint replacement ff. Fibrocystic or other benign breast disease If YES, confirmed by: breast biopsy? MOYR of diagnosis: MOYR of diagnosis: MOYR of diagnosis: MOYR of diagnosis: MOYR of diagnosis: MOYR of diagnosis: MOYR of occurence: MOYR of surgery: MOYR of diagnosis: aspiration? 3. Have you EVER been diagnosed with polycystic ovary syndrome (PCOS)? YEAR of Dx: YYYY 4. What is your CURRENT TOTAL CHOLESTEROL (mgdl) if checked within the past 2 years? <140 mgdl unknownnot checked in 2 yrs 5. What is your CURRENT weight? pounds 6. What is your CURRENT blood pressure (mmhg)? Don't know my blood pressure systolic (upper #) diastolic (lower #) 7. In general, would you say your health is: Excellent Very good Good Fair Poor 8. IN THE PAST MONTH, on approximately how many DAYS did you take any of the following? Please answer on each line. a. Acetaminophen (e.g., Tylenol, Excedrin P.M.) b. Aspirin (e.g., Bayer, Bufferin, Anacin, Excedrin, Ecotrin) c. Medications containing aspirin (e.g., Alka-Seltzer, Doan's Pills, Fiorinal) DAYS USED IN THE PAST MONTH ne On days taking, TOTAL DOSE per day: <100 mg mg mg mg unknown d. n-steroidal, anti-inflammatory agents (e.g., Motrin, Advil, Aleve) 9. Are you CURRENTLY taking any of the following medications REGULARLY? Please indicate NOYES for each. a. Antihypertensives (e.g., diuretic, calcium channel blockers, angiotensin receptor or b-blockers, ACE inhibitor) b. Statin cholesterol-lowering medications (e.g., Lipitor, Zocor, Mevacor, Pravachol, Crestor, Lescol) c. Other non-statin lipid-lowering medications (e.g., niacin, Lopid, Questran, Colestid, Zetia) Page 2 PLEASE GO TO TOP OF NEXT PAGE

3 10. DURING THE PAST YEAR, what was your approximate AVERAGE TIME PER WEEK spent at each of the following recreational activities? a. Walking or hiking (include walking to work) b. Jogging (slower than 10 minute miles) c. Running (10 minute miles or faster) d. Bicycling (include stationary bike) e. Aerobic exercise aerobic dance exercise machines f. Lower intensity exercise yoga stretching toning g. Tennis, squash, or raquetball h. Lap swimming i. Weight lifting strength training j. Other: Please specify activity: 13 zero 1-19 min. AVERAGE TIME PER WEEK min. 1 hour ON AVERAGE, how many FLIGHTS of stairs (not individual steps) do you climb DAILY? ne 1-2 flights 3-4 flights 5-9 flights flights 15 or more flights 12. What is your usual walking pace outdoors? Don't walk regularly Easy, casual (less than 2 mph) rmal, average (2-2.9mph) Brisk pace (3-3.9 mph) Very briskstriding (4 mph or faster) The following items are about activities you might do during a typical day. Does YOUR HEALTH NOW LIMIT YOU in these activities? a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf, limited a lot, limited a little, not limited at all b. Climbing several flights of stairs 14. During the PAST 4 WEEKS, have you had any of the following problems with your work or other regular daily activities AS A RESULT OF YOUR PHYSICAL HEALTH? a. Accomplished less than you would like b. Were limited in the kind of work or other activities 15. During the PAST 4 WEEKS, have you had any of the following problems with your work or other regular daily activities AS A RESULT OF ANY EMOTIONAL PROBLEMS (such as feeling depressed or anxious)? a. Accomplished less than you would like b. Didn't do work or other activities as carefully as usual 16. During the PAST 4 WEEKS, how much did PAIN interfere with your normal work (including both work outside the home and housework)? t at all A little bit Moderately Quite a bit Extremely 17. These questions are about how you feel and how things have been with you during the PAST 4 WEEKS. For each question, please give the one answer that comes closest to the way you have been feeling. How much time during the PAST 4 WEEKS: a. Have you felt calm and peaceful? b. Did you have a lot of energy? c. Have you felt downhearted and blue? All of Most of A good bit of Some of A little of ne of 18. During the PAST 4 WEEKS, how much of has your PHYSICAL HEALTH OR EMOTIONAL PROBLEMS interfered with your social activities (like visiting with friends, relatives, etc.)? All of Most of Some of A little of ne of Questions are taken from the SF-12 Health Survey (Medical Outcomes Trust) QualityMetric Incorporated. Page 3 (OVER)

4 13 YOUR HOME PHONE: YOUR CELL PHONE: YOUR WORK PHONE: THE INFORMATION BELOW ASSISTS US IN MAINTAINING FOLLOW-UP. Name, address and phone of someone at a different address than you whom we may contact if we are unable to reach you: ( ) - - ( ) - - ( ) - - NAME: STREET: CITY: STATE: ZIP: PHONE NO: THIS CONTACT IS: Relative Friend Neighbor Other YOUR ADDRESS: This is the address we have on file: If it has changed, please provide your updated address below: 19. In this question, we are interested in your use of dietary supplements over the PAST 10 YEARS. Please read through the list of supplements. For any that you have taken AT LEAST ONCE PER WEEK FOR A YEAR OVER THE PAST 10 YEARS, complete the information requested. If you have not taken the supplement regularly at any time over the past 10 years, leave the information blank for that supplement and continue down the list. Supplement Multivitamins Vitamin B complex Vitamin A (retinol) YEARS taken in past 10 years Average DAYS PER WEEK Do you take it NOW? Dose per day: <7,000 IU 7,000-15,000 IU 16,000-20,000 IU >20,000+ IU unk Beta-carotene Dose per day: mg mg mg >150 mg unk Vitamin B1 (thiamine) (as single supplement) Dose per day: <11mg mg mg >100 mg unk Vitamin B2 (riboflavin) (as single supplement) Dose per day: <26 mg mg mg >100 mg unk Vitamin B3 (niacin) (as single supplement) Dose per day: <51 mg mg mg >500 mg unk Vitamin B6 (pyridoxine) (as single supplement) Dose per day: <10 mcg mcg mcg >80 mcg unk Vitamin B7 (biotin) (as single supplement) Dose per day: <101 mcg mcg mcg >5000 mcg unk Vitamin B9 (folic acid) (as single supplement) Dose per day: <401 mcg mcg mcg >1000 mcg unk Page 4 PLEASE GO TO TOP OF NEXT PAGE

5 13 Supplement YEARS taken in past 10 years Average DAYS PER WEEK Do you take it NOW? Vitamin B12 (cobalamin) (as single supplement) Dose per day: <26 mcg mcg mcg >500 mcg unk Vitamin C Dose per day: <101 mg mg mg >1000 mg unk Vitamin D (in calcium supplement or separately) Dose per day: <601 IU IU IU >2000 IU unk Vitamin E Dose per day: <101 IU IU IU >1000 IU unk Calcium (incl. elemental calcium in Tums) Dose per day: <400 mg mg mg >1300 mg unk Chromium Dose per day: <201 mcg mcg mcg >1000 mcg unk Iron Dose per day: <25 mg mg mg >70 mg unk Magnesium Dose per day: <41 mg mg mg >350 mg unk Selenium Dose per day: <80 mcg mcg mcg >250 mcg unk Zinc Dose per day: <25 mg mg mg >100 mg unk Supplement YEARS taken in past 10 years Average DAYS PER WEEK Do you take it NOW? Potassium Omega-3 fatty acids (fish oil) Vitamin K Lutein andor zeaxanthin Inositol Choline Amino acids Glucosamine Chondroitin Green tea (EGCG) Coenzyme Q10 Page 5 (OVER)

6 13 Supplement YEARS taken in past 10 years Average DAYS PER WEEK Do you take it NOW? SAMe (s-adenosyl-l-methionine) Cranberry Fiber Probiotics Evening primrose (GLA) Para-aminobenzoic acid (PABA) Alpha-linolenic acid (flaxseed) Ginko biloba Soy phytoestrogen Methylsulfonylmethane (MSM) Omega-9 fatty acids Grape seed Ginseng Ginger Garlic Bilberry Bromelain Quercetin Echinacea Melatonin St. John's wort Copper Iodine PLEASE RETURN ALL PAGES OF THIS FORM (PAGES 1-6) IN THE REPLY ENVELOPE. THANKS. Office use: Page 6