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MEDICAL HISTORY QUESTIONNAIRE

Thank you for showing an interest in our research unit.

This questionnaire helps us to understand your health and medicines. This tells us if you might be suitable for any studies at the moment, and how best we can help you if you come to see us.

Most of the questions just need a tick in the boxes marked 'YES' or 'NO'. Any details given will be treated as strictly confidential. Don't worry if you cannot answer some of the questions. We can go over the questionnaire if you come to the department.

Title
Surname
First Name(s)
Date of Birth (dd/mm/yyyy)
First line of your Address
Second line of your Address
Third line of your Address
Fourth line of your Address
Fifth line of your Address
Postcode (if known)
Home Telephone Number (including area code)
Work Telephone Number(if happy to be contacted on this number)
Mobile Telephone Number
Occupation
eMail Address

BREATHING AND ALLERGIES

Do you think you are in good health?

Yes

How far do you think you could walk before you had to stop?

Do you have any of these health problems?

	Yes	No	Don't know	Age started
Asthma
Eczema
Hayfever
Rhinitis (itchy, streaming or blocked nose)
COPD

If you do have asthma or COPD, have you ever needed:

	Yes	No	If 'Yes', when was the last time?
Prednisolone (steroid) tablets
A & E treatment
Hospital admission

Are you a tobacco smoker?	Yes	No	In the past?

If you didn't answered 'No':

How many cigarettes do you or did you smoke per day?
At what age did you start smoking?
At what age did you stop smoking?

Do you drink alcohol?	Yes	No
If 'Yes', how much do you drink in an average week?

Have you ever taken aspirin?	Yes	No
If 'Yes', did you suffer a reaction to the aspirin?	Yes	No
If 'Yes', what sort of reaction?

Do you have pets or regular contact with animals?	Yes	No
If 'Yes', please give details
Are you alergic to any animals?	Yes	No
If 'Yes', please give details

Are you currently having tests or investigations for any medical condition?	Yes	No
If you answered 'Yes', please give more details here:

MEDICINES

Do you take any medicines or tablets? (Remember to include inhalers, sleeping pills, pain killers and birth control tablets if you take them)	Yes	No
If you answered 'Yes', please give more details here: TABLETS
INHALERS
NASAL SPRAYS
OTHERS
If you come to see us, please remember to bring your medicines. It is the easiest way for us to check exactly what you take!

FAMILY HEALTH

Does anyone in your close family suffer from any of these health problems? (mainly thinking of your parents, brothers, sisters and children)

Asthma	Yes	No
Hayfever	Yes	No
Rhinitis (itchy, streaming or blocked nose)	Yes	No
Exzema	Yes	No
Any other illness	Yes	No
If you answered 'Yes' to 'Any other illness', please give brief details here

OTHER CONTACT DETAILS

Your GP

Name
First line of Address
Second line of Address
Third line of Address
Fourth line of Address
Fifth line of Address
Postcode (if known)
Telephone Number (including area code)
Are you registered with your GP under your current address?	Yes	No
Can we consult your GP about your previous health and medicines?	Yes	No

Next of Kin

Name
First line of Address
Second line of Address
Third line of Address
Fourth line of Address
Fifth line of Address
Postcode (if known)
Telephone Number (including area code)
Relationship to Next of Kin (e.g. spouse, daughter etc)

STUDY DETAILS

Have you taken part in any studies elsewhere?	Yes	No
If you answered 'Yes', please give details of where and when:
Do you agree to having your data and results stored on our password-protected database?	Yes	No

DECLARATION

I agree that you can contact any study groups I have previously participated with and noted above.

I declare that to the best of my knowledge this is a true record of my medical history.

Date form submitted (dd/mm/yyyy):

Thank you for taking the time to complete this questionnaire. Click 'SEND' to agree to the details of the Declaration above, and to submit the form to The Asthma and Allergy Research Group

Form Verification:*

	Yes	No	Don't know
Tuberculosis
Jaundice
Diabetes
High blood pressure
Bronchitis, wheeze, breathlessness or chest trouble
Skin problems
Urinary problems
Heart problems (chest pains, angina, murmurs)
Circulation problems
Epilepsy
Strokes, brain haemorrhage(TB)