Tobacco

Have you EVER smoked cigarettes? (More than 5 packs in a lifetime)

 

 

Yes

 

No

Do you smoke cigarettes NOW? (As of 1 month ago)

 

 

Yes

 

No

Do you AWAKEN during the night to smoke?

 

 

Yes

 

No

How many packs of cigarettes do you smoke per day?

 

 

½ or less

 

1

 

1½

 

2

 

3

 

3½

 

4 or more

How many packs of cigarettes did you smoke per day?

 

 

½ or less

 

1

 

1½

 

2

 

3

 

3½

 

4 or more

How many years have you smoked? (Include past and present)

 

 

1-5

 

6-10

 

11-15

 

16-20

 

21-25

 

26-30

 

31-35

 

36 or more

Alcohol

How often do you have a drink containing alcohol?

 

 

Never

 

Less than monthly

 

2-4 times / month

 

2-4 times / week

 

Daily

How many drinks containing alcohol do you have on a typical day when you are drinking?

 

 

1-2

 

3-4

 

5-6

 

7-8

 

9 or more

How often do you have six or more drinks containing alcohol?

 

 

Never

 

Less than monthly

 

2-4 times / month

 

2-4 times / week

 

Daily

Caffeine

Use the information given below to estimate the number of ounces.

Small cup = 5 oz, Regular or small mug / cup = 8 oz, Large mug = 12 oz, Regular can of soda / cola = 12 oz, Regular bottle of water = 20 oz

On a typical day, how many ounces of caffeinated coffee, tea, cola/sodas do you drink?
(Please choose one response per beverage - DO NOT include decaffeinated beverages)

Coffee

 

 

None

 

Less than 8 oz

 

8-16 oz

 

16-24 oz

 

24-48 oz

 

48-72 oz

 

More than 72 oz

Tea

 

 

None

 

Less than 8 oz

 

8-16 oz

 

16-24 oz

 

24-48 oz

 

48-72 oz

 

More than 72 oz

Colas/Sodas

 

 

None

 

Less than 8 oz

 

8-16 oz

 

16-24 oz

 

24-48 oz

 

48-72 oz

 

More than 72 oz

How often do you use pills containing caffeine (e.g. No Doz)?

 

 

Never

 

Less than monthly

 

2-4 times / month

 

2-4 times / week

 

Daily

Recreational Drug Use

Do you use any illegal drugs or substances (marijuana, cocaine, etc)?

 

 

Yes

 

No

MEDICAL HISTORY

 

Fibromyalgia

 

Stomach Ulcers

 

Seizures / Epilepsy

 

Trauma

 

Kidney Failure

 

Stroke

 

Vision / Hearing Loss

 

Kidney Stones

 

Anxiety Disorder

 

Chronic / Frequent SinusitisHay

 

Bladder Problems

 

Bipolar Disorder

 

Deviated Septum

 

Urinary Tract Infections

 

Depression

 

Angina

 

Dialysis

 

History of Psychiatric Treatment

 

Coronary Artery Disease

 

Prostate Problems

 

Diabetes

 

Pacemaker

 

Impotence / Erectile Dysfunction

 

Anemia

 

Heart Attack

 

Gynecological Problems

 

Clots in Leg or Lung

 

Heart Defibrillator

 

Polycystic Ovarian Syndrome

 

Hepatitis

 

Heart Failure

 

High Cholesterol

 

Heart Murmur

 

Poor Leg Circulation

 

High Blood Pressure

 

Thyroid Disease

 

Irregular Heart Rhythm

 

Lung Cancer

 

Asthma

 

Breast Cancer

 

Chronic Bronchitis

 

Colon Cancer

 

Emphysema / COPD

 

Chronic / Intermittent Back Pain

 

Prostate Cancer

 

Pneumonia

 

Osteoarthritis

 

Leukemia / Lymphoma

 

Acid Reflux

 

Rheumatoid Arthritis

 

Other Cancer

 

Gall Bladder Disease

 

Gout

 

Hay Fever

 

Pancreatitis

 

Headaches

 

Other Medical Problem

 

Hiatal Hernia

 

Paralysis

 

Irritable Bowel Syndrome

 

Parkinson's Disease

Arthritis in:

 

 

Hands

 

Hips

 

Knee

 

Shoulders

 

Spinal

 

NO Known Medical Problems

SURGICAL HISTORY

 

Appendectomy (Appendix)

 

Eye / Cataract Surgery

 

Ovaries Removed

 

Breast Surgery

 

Gastric Bypass / Lap-band

 

Plastic Surgery

 

Caesarean Section

 

Hernia Repair

 

Prostate Surgery

 

Cardiac Angioplasty / Stent

 

Hysterectomy (Uterus)

 

Sinus Surgery

 

Cardiac Bypass Surgery

 

Jaw Surgery

 

Throat Surgery for Snoring

 

Carotid Surgery

 

Joint Replacement

 

Tonsillectomy (Tonsils)

 

Cholecystectomy (Gall Bladder)

 

Nasal Surgery

 

Other Surgery

 

Colon Surgery

 

Orthopedic Surgery

 

NO Surgeries

FAMILY HISTORY

Sleep Apnea found during a Sleep Study

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Narcolepsy

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Restless Legs Syndrome

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Heavy Snoring

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Sleep Walking / Sleep Terrors

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Insomnia

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Diabetes

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

High Blood Pressure

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Congenital Heart Disease

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Coronary Heart Disease

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Thyroid Disease

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Stroke

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Seizures

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Abnormal Heart Rhythm

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Neurologic Disorders

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Cancer

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Developed Heart Disease before Age 60?

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other

Psychiatric Illness

 

 

Father

 

Mother

 

Brother

 

Sister

 

Child

 

Grandparent

 

Other