Part 1.
Regarding this consumer survey:
______________________________________
This is a: New Health
History Survey submission
Update to a previous Health History Survey submission
My previous Health History Survey confirmation number was |
1. I live in the following country, province or
state: |
2. This health history survey concerns: Other |
3. My experience is: Other |
4. The frequency of my contact with the patient was: |
5. My contact was: Other |
6. I date my contact as closely as possible From & To: |
7. The patient's illness was first diagnosed while living in:
Country:
Prior to diagnosis the patient had
lived in nation(s):
Specifically, the patient has lived in the
following countries, region(s) & section(s):
NOTE: Please specify each time period(s) & location(s).
Most recent time period & location:
Prior time period & location:
Additional time period(s) & location(s):
|
8. Today the patient's condition is: Other |
|
Part 2. Regarding the patient:
________________________ |
| 1.
Environmental factors: Did the patient: NOTE: Specify From & To Dates
of use.
|
Live
in a major metropolitan area?
Specify From & To Dates Use
under-arm anti-perspirants?
Specify From & To Dates
Use aluminum cookware?
Specify From & To Dates
List other factors: |
|
| 2.
Dietary habits: Did the patient: NOTE: Specify From & To Dates
of use.
|
Eat spicy foods
often?
Specify From & To Dates Eat greasy foods
often?
Specify From & To Dates
Follow a vegetarian life-style?
Specify From & To Dates
List other factors: |
|
| 3.
Exercise: Did the patient: NOTE: Specify From & To Dates of use.
|
Exercise more
than 4 times a week?
Specify From & To Dates Exercise 3 or
less times a week?
Specify From & To Dates
Did
not exercise.
Specify From & To Dates
List other factors: |
|
4.
Medication used before onset
of this disease:
NOTE: Specify From & To Dates of use.
|
Anti-hypertensives?
Specify From & To Dates Cholesterol lowering?
Specify From & To Dates
Psychotropic?
Specify From & To Dates
Hormone replacement therapy?
Specify From & To Dates
List other medications: |
|
| 5.
Family history:
NOTE: If you are unsure of any or all of these points, please leave them blank. |
Parents had cancer?
Father Age /
Mother AgeDiabetes in immediate family?
Specify specific relative(s)
Heart disease?
Father Age /
Mother Age
Alzheimer's disease in family?
Relationship(s)
List other diseases in immediate family: |
|
Part 3. Regarding your knowledge &
perceptions of medical technology:
_______________________________________________________ |
| 6.
Gene technology: Please check all points that you agree with. |
I
have heard of the human genome project.
I have no idea
what the human genome project is.
The
human genome project identifies disease
development.
The
human genome project will probably not
lead to disease prevention and cures.
More government money should be applied to
the human genome project. |
|
| 7.
Organ donation: Please check all points that you agree with. |
I have signed-up to donate organs at my death.
I would donate but
don't know how to sign-up.
I would never
donate my organs upon my death.
I hope organs are
available if I need them.
The idea of organ
replacement is confusing.
|
|
Part 4. Regarding your medical insurance:
_______________________________________________________ |
| 8.
Do you have medical insurance? |
Yes
No |
|
9.
If you do not have
medical insurance,
how concerned are you? |
Very Somewhat
Not
very |
|
10. If you do have
medical insurance,
who pays the premiums? |
My employer pays 100%
My employer pays most, but
not all, of the cost
My employer
pays some, but I don't know how much
I pay 100% and buy my own
insurance
Other: |
| 11.
I am: |
Female
Male |
12. My
age group is:
|
Under 20
20-29
30-39
40-49
50-59
60-69
70-79
Over 80 |
|
| Do you have a question about this topic? |
About Submitting Information
Information will only be used to statistically
tally results by HealthHistorySurvey.com. No information will be used for anything
other than statistical tallying. Results will be shared only with fully accredited
medical research organizations.
As appropriate, your experiences will be added to the disease
category file. HealthHistorySurvey will statistically tally first-hand observations
to find correlations.
While HealthHistorySurvey.com cannot remedy any problems or diseases, your first-hand experiences may
assist in identifying or pointing to specific disease causes.
By sharing your experiences you may increase
the possibility of pointing research in specific directions. |
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