HEALTH STUDY PLEASE USE A BALL-POINT PEN WHEN COMPLETING THIS QUESTIONNAIRE. IT IMPROVES THE QUALITY OF OUR DATA. 1. Birth date: Last 6 digits of SSN: (optional) 2. 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 (month/year) of the diagnosis or the procedure. DIAGNOSIS OR PROCEDURE IF YES, PROVIDE MO/YR IN BOXES BELOW
a. Acute coronary syndrome/unstable angina
If YES, confirmed by: angiogram/cardiac cath?
d. Coronary angioplasty (PTCA or PCI) or stent
i. Peripheral artery disease (not varicose veins)
n. Carotid artery surgery (endarterectomy)
t. Other cancer (not including any of the above cancers)
HEALTH STUDY 2. (continued) NEWLY DIAGNOSED IN LAST 2 YEARS? IF YES, PROVIDE DATE (MO/YR) IN BOXES BELOW RIGHT eye RIGHT eye RIGHT eye
ee. Elevated cholesterol (NEW dx by a clinician)
kk. Fibrocystic or other benign breast disease
3. In general, would you say your health is: 4. What is your CURRENT TOTAL CHOLESTEROL (mg/dl) if checked within the past 2 years? 5. What is your CURRENT HDL-CHOLESTEROL (mg/dl) if checked within the past 2 years? 6. Do you CURRENTLY smoke cigarettes?
If YES: On average, how many cigarettes/day
7. What is your CURRENT weight? 8. What is your CURRENT blood pressure (mmHg)? PLEASE GO TO TOP OF NEXT PAGE HEALTH STUDY 9. DURING THE PAST YEAR, what was your approximate AVERAGE TIME PER WEEK AVERAGE TIME PER WEEK spent at each of the following recreational activities? hours hours
a. Walking or hiking (include walking to work)
e. Aerobic exercise / aerobic dance / exercise machines
f. Lower intensity exercise / yoga / stretching / toning
j. Other: Please specify activity: _____________________
10. ON AVERAGE, how many FLIGHTS of stairs (not individual steps) do you climb DAILY? 11. What is your usual walking pace outdoors? AVERAGE TIME PER WEEK 12. DURING THE PAST YEAR, on average, how many HOURS PER WEEK did you spend:
a. Sitting at work or away from home or while driving
b. Sitting at home while watching TV/VCR/DVD
c. Other sitting at home (e.g., reading, meal times, at desk)
13. IN THE PAST 2 YEARS, have you used female hormones?
a. IF YES, in the PAST 2 YEARS, for how many months have you used female hormones?
b. Are you CURRENTLY using them (within the last month)?
c. Mark the type(s) of hormones you have used the longest in the PAST 2 YEARS:
d. If you used oral conjugated estrogens (e.g., Premarin) what dose did you usually take?
HEALTH STUDY 14. IN THE PAST MONTH, on approximately how many DAYS did you take any DAYS USED IN THE PAST MONTH 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)
d. Other non-steroidal, anti-inflammatory agents (e.g., Motrin, Advil, Aleve)
f. SINGLE supplements of omega-3 fatty acids (fish oil)
g. SINGLE supplements of calcium (include elemental calcium in Tums)
h. SINGLE supplements of vitamin D (in calcium supplements or separately)
15. Are you CURRENTLY taking any of the following medications REGULARLY? Please indicate NO/YES 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)
d. Fosamax or other bisphosphonates for prevention/treatment of bone loss
If YES, for how many years have you been regularly taking this bone loss med.?
16. IN THE PAST YEAR, have you had any of the following? (Please answer on (Please answer on each line) each line) symptoms screening symptoms screening 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 Neighbor
PREFERRED DRUG LIST CONVERSION TABLE January 2002 BOLD TYPEFACE indicates product is available at the preferred generic copayment tier. CAPS indicates product is available at the preferred brand copayment tier. NON-PREFERRED DRUG PREFERRED ALTERNATIVE Ranitidine 300mg Cimetidine 800mg Famotidine 40mg Cardiovascular Agents – Calcium Channel Blockers Diltiaz
SLEEP APNEA SYNDROMES The mysteries of sleep have intrigued man for centuries, it has only been within last three decades that we have begun to understand physiology and physiopatology of this state that occupies a considerable portion of our lives. It was developped a better understanding of specific sleep disorders and their realationship to common medical problems seen during wakefulnes