ISU– MEDICAL HISTORY
Today’s Date: _____/_____/_____
Personal Information
Name:_______________________ Age:_____Date of Birth: _____/_____/_____ Sex:______
Address: _______________________________________Telephone No: (____)___________
Employer: ______________________________________Social Security No: _____-_____-______
Emergency Information
Personal
Physician’s
Physician: __________________________________________ Telephone No: ____________
Physician’s
Address: ____________________________________________________________________
Individual to be contacted in case of an emergengy: __________________________________
Relationship to you: ____________________________
Home
Address: _____________________________________
Home
Telephone No: _________________
Work
Address: _____________________________________
Work
Telephone No: ________________
Do you have medical alert identification? _________ YES _______NO
If YES, where is it located? ______________________________________________
Are you a current or former smoker ______ YES _____ NO
If YES, describe smoking history __________________________________________
Current Medications (include ALL medications)
Name of Drug
Dosage; Times/day
Why are you on this drug?
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Hospitalizations
Please list the last three (3) times you have been ill (sick) enough to see a physician, been hospitalized or had surgery.
When?
What was done (surgery, etc.)?
Why was this done?
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Personal Medical History
Do you have any known allergies? ______ YES ______NO If YES, please explain:_______________________
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Please check the following disease conditions that you had or currently have:
____ High blood pressure
____ Aneurysm
____ High blood cholesterol
____ Anemia
____ High blood triglycerides
____ Diabetes
____ Angina pectoris
____ Jaundice
____ Heart attack
____ Hepatitis
____ Heart surgery (catheter, bypass) ____ Infectious mononucleosis
____ Heart failure
____ Phlebitis
____ Heart murmur
____ Gout
____ Stroke/transient ischemia attacks ____ Kidney stones
____ Rheumatic fever
____ Urinary tract infections
____ Arteriosclerosis
____ Emotional disorder (depression, etc.)
____ Abnormal chest X-ray
____ Asthma
____ Emphysema
____ Bronchitis
____ Thyroid problems
____ Hernia
____ Cancer
____ Epilepsy or seizures
____ Prostate problem
____ Osteoporosis
____ Eating disorder
____ Other
Please provide dates and explanation to any of the above which you checked: _______________________
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Recent Illness
Have you had any symptoms of illness within the last 3 weeks (such as runny nose, stuffy nose, sore throat, fever,
aches, etc) ________ YES _______ NO If YES, please list the symptoms that you experienced:
Have you taken any medication within the last 3 weeks for symptoms of illness or pain (aspirin, tylenol, ibuprofen,
over the counter cold medications, etc) ________ YES _______ NO
If YES, please describe:
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Prior Influenza Immunization
Have you received an influenza immunization before? _________ YES ________ NO
If yes, please circle the years that you received the vaccine
2002
2001
2000
1999
1998
Activity History
Please list any physical or recreational activities that you currently do or have done on a regular basis.
List each activity below (ACTIVITIES MAY INCLUDE: walking, hiking, swimming, jogging, water
exercise class, calisthenic exercises, badminton, basketball, exercise bicycle, bicycle outdoors, dancing –
please list type of dance, farm work – please describe, gardening, golf, horseback riding, skiing-downhill,
skiing-cross country, tennis, racquetball, OR ANY OTHER ACTIVITY THAT MAKES YOU BREATHE
HARDER)
Activity
Frequency (days/week)
Time (min/session)
How long (years)
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Vitamin and Nutritional Supplement Intake
Please list below all of the vitamins, minerals, and nutritional supplements you consume
NAME
AMOUNT
HOW OFTEN?
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THANK YOU FOR YOUR COOPERATION!
If you have any questions or concerns please call: Dr. Marian Kohut, Ph.D., 294-8364
SOCIAL ACTIVITY QUESTIONNAIRE
NAME _________________________________
Social Activities
Please list any social activities that you currently do or have done on a regular basis. Report those
activities that you do at least once every 2 months. (Examples of activities: attending classes,
playing cards, bowling club, gardening club, member of religious or non-religious social group,
church visits, visiting family members, visiting friends, OR ANY OTHER ACTIVITIES THAT
INVOLVE SOCIAL INTERACTION WITH OTHER PEOPLE)
Activity
Frequency (days/week)
Time (min/session)
How long (years)
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THANK YOU FOR YOUR PARTICIPATION IN THE RESEARCH STUDY
PLEASE RETURN TO THE ________________________________________
ON ___________________________ AT _______________________________
We will collect a small blood sample from you on this day.
SIDE EFFECTS FOLLOWING THE FLU SHOT
If you experience any side effects from the flu shot please describe below:
ON THE DAY YOU RETURN FOR YOUR BLOOD SAMPLE:
Please bring all forms back with you (medical history, diet analysis, consent form).
We will ask you to complete a short questionnaire about your attitudes and stress in
your daily life.
We will also serve a light breakfast.
APPROXIMATELY ONE MONTH AFTER THE BLOOD DRAW, OUR
REGISTERED DIETITIAN WILL CALL YOU WITH THE RESULTS OF YOUR
DIET ANALYSIS.
THANK YOU FOR YOUR PARTICIPATION. PLACE A CHECK BELOW IF YOU
WOULD LIKE TO SEE A COPY OF THE RESULTS FROM THIS STUDY.
______ Please mail me a copy of the results
______ Please call me with information about the results