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?YesNo

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





Do you have any of these health problems?

 YesNoDon't knowAge started
Asthma
Eczema
Hayfever
Rhinitis (itchy, streaming or blocked nose)
COPD


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

 YesNoIf 'Yes', when was the last time?
Prednisolone (steroid) tablets
A & E treatment
Hospital admission





Are you a tobacco smoker?YesNoIn 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?YesNo
If 'Yes', how much do you drink in an average week?





Have you ever taken aspirin?YesNo
If 'Yes', did you suffer a reaction to the aspirin?YesNo
If 'Yes', what sort of reaction?





Do you have pets or regular contact with animals?YesNo
If 'Yes', please give details
Are you alergic to any animals?YesNo
If 'Yes', please give details





OTHER HEALTH PROBLEMS



Have you had any of the following health problems? (if 'Yes', you can give details below)

 YesNoDon'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)

If you answered 'Yes' to any of the health questions above, please give more details here:



If you have any other medical problems that we left out, please give more details here:



Are you currently having tests or investigations for any medical condition?YesNo

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)
YesNo
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)

AsthmaYesNo
HayfeverYesNo
Rhinitis (itchy, streaming or blocked nose)YesNo
ExzemaYesNo
Any other illnessYesNo
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?YesNo
Can we consult your GP about your previous health and medicines?YesNo

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?YesNo
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?
YesNo





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





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