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March26 2009 Health Questionnaire

March26 2009 Health Questionnaire

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Published by Anita Ikonen
This is the questionnaire that was used at the FACT Meeting of March 2009 with two members of the group.
This is the questionnaire that was used at the FACT Meeting of March 2009 with two members of the group.

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Published by: Anita Ikonen on Mar 27, 2009
Copyright:Attribution Non-commercial

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01/30/2013

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Study – Winston Salem, March of 2009
Volunteer’s.Health.Form
Form ID #
9087
Male
FemaleAge _________ 
*Optional 
PAINwhen perceived lastextent
Head, headaches, migraine
current | within a week ago | longer ago
1 2 3 4 
5
Throat or front of neck 
current | within a week ago | longer ago
1 2 3 4 
5
Back of neck 
current | within a week ago | longer ago
1 2 3 4 
5
Left shoulder 
current | within a week ago | longer ago
1 2 3 4 
5
Right shoulder 
current | within a week ago | longer ago
1 2 3 4 
5
Left arm
current | within a week ago | longer ago
1 2 3 4 
5
Right arm
current | within a week ago | longer ago
1 2 3 4 
5
Left hand or left wrist
current | within a week ago | longer ago
1 2 3 4 
5
Right hand or right wrist
current | within a week ago | longer ago
1 2 3 4 
5
Chest area
current | within a week ago | longer ago
1 2 3 4 
5
Upper abdomen
current | within a week ago | longer ago
1 2 3 4 
5
Left side of abdomen
current | within a week ago | longer ago
1 2 3 4 
5
Right side of abdomen
current | within a week ago | longer ago
1 2 3 4 
5
Lower abdomen
current | within a week ago | longer ago
1 2 3 4 
5
Hip or pelvic area
current | within a week ago | longer ago
1 2 3 4 
5
Upper back 
current | within a week ago | longer ago
1 2 3 4 
5
Middle back 
current | within a week ago | longer ago
1 2 3 4 
5
Lower back 
current | within a week ago | longer ago
1 2 3 4 
5
Left leg
current | within a week ago | longer ago
1 2 3 4 
5
Right leg
current | within a week ago | longer ago
1 2 3 4 
5
Left knee
current | within a week ago | longer ago
1 2 3 4 
5
Right knee
current | within a week ago | longer ago
1 2 3 4 
5
Left foot
current | within a week ago | longer ago
1 2 3 4 
5
Right foot
current | within a week ago | longer ago
1 2 3 4 
5
Heart
current | within a week ago | longer ago
1 2 3 4 
5
Stomach
current | within a week ago | longer ago
1 2 3 4 
5
Other pain
Write area of the other pain:
current | within a week ago | longer ago
1 2 3 4 
5
Page 1 of 4
 
Study – Winston Salem, March of 2009
Volunteer’s.Health.Form
Form ID #
9087
JOINT PROBLEMS
defined as reduced mobility of a joint joint that locks, and/or has pain
when perceived lastextent
Jaw
current | within a week ago | longer ago
1 2 3 4 
5
 Neck 
current | within a week ago | longer ago
1 2 3 4 
5
Left Shoulder 
current | within a week ago | longer ago
1 2 3 4 
5
Right Shoulder 
current | within a week ago | longer ago
1 2 3 4 
5
Left Elbow
current | within a week ago | longer ago
1 2 3 4 
5
Right Elbow
current | within a week ago | longer ago
1 2 3 4 
5
Left Wrist
current | within a week ago | longer ago
1 2 3 4 
5
Right Wrist
current | within a week ago | longer ago
1 2 3 4 
5
Left hand Fingers
current | within a week ago | longer ago
1 2 3 4 
5
Right hand Fingers
current | within a week ago | longer ago
1 2 3 4 
5
Spine
current | within a week ago | longer ago
1 2 3 4 
5
Left side Hip/Thigh joint
current | within a week ago | longer ago
1 2 3 4 
5
Right side Hip/Thigh joint
current | within a week ago | longer ago
1 2 3 4 
5
Left Knee
current | within a week ago | longer ago
1 2 3 4 
5
Right Knee
current | within a week ago | longer ago
1 2 3 4 
5
Left Ankle
current | within a week ago | longer ago
1 2 3 4 
5
Right Ankle
current | within a week ago | longer ago
1 2 3 4 
5
Left Foot or Toes
current | within a week ago | longer ago
1 2 3 4 
5
Right Foot or Toes
current | within a week ago | longer ago
1 2 3 4 
5
BONE PROBLEMS
defined as pain, reduced function etc.
when perceived lastextent
Cranium
current | within a week ago | longer ago
1 2 3 4 
5
 Neck vertebrae, collar bone
current | within a week ago | longer ago
1 2 3 4 
5
Upper back spine
current | within a week ago | longer ago
1 2 3 4 
5
Middle back spine
current | within a week ago | longer ago
1 2 3 4 
5
Lower back spine
current | within a week ago | longer ago
1 2 3 4 
5
Chest, ribcage
current | within a week ago | longer ago
1 2 3 4 
5
Left side Hip and pelvic
current | within a week ago | longer ago
1 2 3 4 
5
Right side Hip and pelvic
current | within a week ago | longer ago
1 2 3 4 
5
Left Shoulder 
current | within a week ago | longer ago
1 2 3 4 
5
Right Shoulder 
current | within a week ago | longer ago
1 2 3 4 
5
Left arm or hand
current | within a week ago | longer ago
1 2 3 4 
5
Right arm or hand
current | within a week ago | longer ago
1 2 3 4 
5
Left leg or foot
current | within a week ago | longer ago
1 2 3 4 
5
Right leg or foot
current | within a week ago | longer ago
1 2 3 4 
5
Page 2 of 4
 
Study – Winston Salem, March of 2009
Volunteer’s.Health.Form
Form ID #
9087
SPECIAL CONDITIONSwhen or whereextent
Fractured bone most recent
recent | month | 6 months | year | longer 
1 2 3 4 
5
What bone was fracturedand the extent of the fracture:
scull, neck | left arm, hand | right arm, handcollarbone | rib | spine | hip | L leg | R legIs there any remaining discomfort or damage after the fracture, describe:
1 2 3 4 
5
Have you had surgeries, which
Implants, screws, staples, after surgery:
Large scars and where
1 2 3 4 
5
Removed organs
kidney | gall bladder | appendix | tonsils
Missing your own naturaltooth or teeth in what area(s)
upper jaw left side | upper jaw right sidelower jaw left side | lower jaw right side
Do you exercise, how often
daily | weekly | monthly | few times a year 
1 2 3 4 
5
Heart problem
now | past week | month | year | longer 
1 2 3 4 
5
(Women) Pregnant
few days | month | 2-5 months | 6-9 months
(Men) Vasectomy
DISCOMFORTSwhen or whereextent
Permanent ”objects” in field of vision
Describe shape, placement, and size:left eye | right eye | both eyes
1 2 3 4 
5
Bad hearing in Left ear 
1 2 3 4 
5
Bad hearing in Right ear 
1 2 3 4 
5
Tinnitus (ringing in Left ear)
1 2 3 4 
5
Tinnitus (ringing in Right ear)
1 2 3 4 
5
Dizziness
current | within a week ago | longer ago
1 2 3 4 
5
Confusion
current | within a week ago | longer ago
1 2 3 4 
5
Anxiety
current | within a week ago | longer ago
1 2 3 4 
5
Hands get cold due to circulation
current | within a week ago | longer ago
1 2 3 4 
5
Feet get cold due to circulation
current | within a week ago | longer ago
1 2 3 4 
5
Asthma
current | within a week ago | longer ago
1 2 3 4 
5
Cough
current | within a week ago | longer ago
1 2 3 4 
5
Phlegm in respiratory system or lungs
 
current | within a week ago | longer ago
1 2 3 4 
5
Low oxygen uptake
current | within a week ago | longer ago
1 2 3 4 
5
Do you smoke (when last)
current | within a week ago | longer ago
1 2 3 4 
5
 Numbness, loss of sensation
Which body part becomes numb:
current | within a week ago | longer ago
1 2 3 4 
5
Kidney stones
current | within a week ago | longer ago
1 2 3 4 
5
Gall stones
current | within a week ago | longer ago
1 2 3 4 
5
Trouble swallowing
current | within a week ago | longer ago
1 2 3 4 
5
 Need to use restroom now
1 2 3 4 
5
Page 3 of 4

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