Medical History - National Institutes of Health



Date history taken:General Immune/Infectious SymptomsAt onset (within first month of illness), did participant/subject experience any of the following? If yes, are any of those symptoms current?(check all that apply)* FORMCHECKBOX Fevers FORMCHECKBOX Current FORMCHECKBOX Chills FORMCHECKBOX Current FORMCHECKBOX Night sweats FORMCHECKBOX Current FORMCHECKBOX Sore throats FORMCHECKBOX Current FORMCHECKBOX Swollen/tender glands FORMCHECKBOX Current FORMCHECKBOX Rashes FORMCHECKBOX Current FORMCHECKBOX Nausea/vomiting/diarrhea (N/V/D) FORMCHECKBOX Current FORMCHECKBOX Arthalgia/arthritis FORMCHECKBOX Current FORMCHECKBOX Mouth ulcers FORMCHECKBOX Current FORMCHECKBOX History of autoimmune disease FORMCHECKBOX Current FORMCHECKBOX Family history of autoimmune disease (biological relatives only, if applicable) FORMCHECKBOX CurrentDoes the participant/subject have a history of repeated or long term antibiotic use? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what antibiotic(s): Indication:When (year(s)):Does the participant/subject have a history of any of the following illnesses or conditions? (check all that apply, describe symptoms at onset)ConditionSymptoms at OnsetYear of DiagnosisZosterImmunodeficiency syndrome(s):-Name of syndrome:Malignancy (cancer) affecting the immune system:-Name of syndrome:Food hypersensitivity FORMCHECKBOX No FORMCHECKBOX YesIf yes, indicate which ones and type of reaction:Food ComponentHave Hypersensitivity?Reaction (hives, vomiting, other)Date of OnsetLactose FORMCHECKBOX Gluten (any intolerance) FORMCHECKBOX Gluten (celiac disease) FORMCHECKBOX Milk protein FORMCHECKBOX Alcohol FORMCHECKBOX Eggs FORMCHECKBOX Sugar/Fructose FORMCHECKBOX Caffeine FORMCHECKBOX Nuts FORMCHECKBOX Chocolate FORMCHECKBOX Aspartame FORMCHECKBOX Other, specify: FORMCHECKBOX Adverse drug reactions (if yes, specify): FORMCHECKBOX No FORMCHECKBOX Yes: If yes, list drugs and route and year(s) of administration:Drug nameRouteReactionYear(s) receivedHistory of atopy/allergic disorders FORMCHECKBOX No FORMCHECKBOX YesIf yes, indicate which ones, whether a problem in the last year, whether currently a problem, whether you take medications for allergies :Condition diagnosisIf diagnosed:Medication(s) name(s): FORMCHECKBOX Allergic rhinitis/hay fever FORMCHECKBOX Condition active past one year FORMCHECKBOX Condition currently active FORMCHECKBOX Medications are taken for this condition FORMCHECKBOX Medications taken daily for condition FORMCHECKBOX Asthma FORMCHECKBOX Condition active past one year FORMCHECKBOX Condition currently active FORMCHECKBOX Medications are taken for this condition FORMCHECKBOX Medications taken daily for condition FORMCHECKBOX Atopic dermatitis FORMCHECKBOX Condition active past one year FORMCHECKBOX Condition currently active FORMCHECKBOX Medications are taken for this condition FORMCHECKBOX Medications taken daily for condition FORMCHECKBOX Hives FORMCHECKBOX Condition active past one year FORMCHECKBOX Condition currently active FORMCHECKBOX Medications are taken for this condition FORMCHECKBOX Medications taken daily for condition FORMCHECKBOX Mast cell activation syndrome FORMCHECKBOX Condition active past one year FORMCHECKBOX Condition currently active FORMCHECKBOX Medications are taken for this condition FORMCHECKBOX Medications taken daily for condition FORMCHECKBOX Other, specify: FORMCHECKBOX Condition active past one year FORMCHECKBOX Condition currently active FORMCHECKBOX Medications are taken for this condition FORMCHECKBOX Medications taken daily for conditionHistory of unusual vaccines (e.g., related to international travel) FORMCHECKBOX No FORMCHECKBOX YesIf yes, list which vaccines and year(s) of administration:Vaccine NameYears(s) ReceivedIrritable Bowel Syndrome CriteriaROME I Criteria**: At least 3 months of continuous or recurrent symptoms: FORMCHECKBOX 1. Abdominal pain or discomfort that is: FORMCHECKBOX Relieved with defecationand/or FORMCHECKBOX Associated with a change in frequency of stooland/or FORMCHECKBOX Associated with a change in consistency of stoolPLUS: FORMCHECKBOX 2. Two or more of the following, on at least one-fourth of occasions or days: FORMCHECKBOX Altered stool frequency (for research purposes, “altered” may be defined as more than three bowel movements each day or fewer than three bowel movements each week) FORMCHECKBOX Altered stool form (lumpy and hard, or loose and watery) FORMCHECKBOX Altered stool passage (straining, urgency, or a feeling of incomplete evacuation) FORMCHECKBOX Passage of mucus FORMCHECKBOX Bloating or feeling of abdominalRome I criteria: FORMCHECKBOX YES FORMCHECKBOX NO.ROME II Criteria**: Abdominal distention or pain of at least 12 weeks duration (not necessarily consecutive weeks) in the preceding 12 months accompanied by two of the following three features of altered bowel habits: FORMCHECKBOX Relieved with defecation FORMCHECKBOX An onset associated with change in the frequency of stool FORMCHECKBOX An onset associated with change in the form (appearance) of stoolRome II criteria: FORMCHECKBOX YES FORMCHECKBOX NOROME III Diagnostic Criteria for Irritable Bowel Syndrome**:Recurrent abdominal pain or discomfort at least 3 days per month for the past 3 months AND two or more of the following symptoms: FORMCHECKBOX Improvement with defecation FORMCHECKBOX Onset associated with a change in frequency of stool FORMCHECKBOX An onset associated with change in the form (appearance) of stoolMeets Rome III Diagnostic Criteria for Irritable Bowel Syndrome: FORMCHECKBOX YES FORMCHECKBOX NOIrritable Bowel Syndrome (IBS) Subtypes by Predominant Stool PatternYou must not be taking laxatives or antidiarrheal medicines that will change your bowel habits. FORMCHECKBOX 1. IBS with Constipation (IBS-C):Hard or lumpy stool (Type 1 or 2) with more than 25% of bowel movements, and loose or watery stools (Type 6 or 7) with less than 25% of bowel movements. FORMCHECKBOX 2.IBS with Diarrhea (IBS-D):Loose or watery stools (Type 6 or 7) with more than 25% of bowel movements, and hard or lumpy stools (Type 1 or 2) with less than 25% of bowel movements. FORMCHECKBOX 3. Mixed IBS (IBS-M):Hard or lumpy stool (Type 1 or 2) with more than 25% of bowel movement, plus loose or watery stool (Type 6 or 7) with more than 25%, of bowel movements. FORMCHECKBOX 4. Unsubtyped IBS:Insufficient abnormality of stool consistency to meet criteria for IBS-C,IBS-D or IBS-M.Medical History QuestionnairePlease check any EYE conditions that are still active and/or for which you are taking medicationsCondition DiagnosedYear(s) of DiagnosisCondition ActiveTake Medications (past year)Currently Take MedicationsMedication name(s)Medication(s) work wellCondition no longer active/resolved FORMCHECKBOX Optic neuritis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Uveitis or scleritis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Eye infections FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Dry eye FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Sjogren's syndrome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Other, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Please check any EAR, NOSE and/or THROAT conditions that are still active and/or for which you are taking medicationsCondition DiagnosedYear(s) of DiagnosisCondition ActiveTake Medications (past year)Currently Take MedicationsMedication name(s)Medication(s) work wellCondition no longer active/resolved FORMCHECKBOX Chronic sinusitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Chronic rhinitis (runny nose) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Impaired hearing FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Easy nasal bleeding FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Nasal allergies FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Chronically infected tonsils FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Tonsillectomy FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Hay fever FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Chronic/repeated otitis media (ear infections) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Other, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Please check any LUNG conditions that are still active and/or for which you are taking medicationsCondition DiagnosedYear(s) of DiagnosisCondition ActiveTake Medications (past year)Currently Take Medications Medication name(s)Medications work wellCondition no longer active/resolved FORMCHECKBOX Pneumonia, ever FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Pneumonia in the past 12 weeks FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Pleurisy FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Asthma (as a child) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Asthma (as an adult) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Bronchitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Emphysema FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Chronic obstructive lung disease (COPD or COLD) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Chronic restrictive lung disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Silicosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Asbestosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Other, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Please check any GUT conditions that are still active and/or for which you are taking medicationsCondition DiagnosedYear(s) of DiagnosisCondition ActiveTake Medications (past year)Currently Take Medications Medication name(s)Medications work wellCondition no longer active/resolved FORMCHECKBOX Peptic ulcer FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Hiatus hernia FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Hepatitis, type unspecified FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Hepatitis A FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Hepatitis B FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Hepatitis C FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Gall bladder disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Liver disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Cirrhosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Pancreatitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Chronic pancreatitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Celiac disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Irritable bowel syndrome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Crohn's disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Ulcerative colitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Colorectal cancer FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Other, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Please check any SKIN conditions that are still active and/or for which you are taking medicationsCondition DiagnosedYear(s) of DiagnosisCondition ActiveTake Medications (past year)Currently Take Medications Medication name(s)Medications work wellCondition no longer active/resolved FORMCHECKBOX Hives FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Psoriasis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Eczema FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Contact dermatitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Dermatomyositis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Vasculitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Zoster FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Other allergic skin reactions FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Other, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Please check any BLOOD and/or IMMUNE SYSTEM conditions that are still active and/or for which you are taking medicationsCondition DiagnosedYear(s) of DiagnosisCondition ActiveTake Medications (past year)Currently Take MedicationsMedication name(s)Medications work wellCondition no longer active/resolved FORMCHECKBOX Anemia FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Sickle cell disease FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Thalassemia FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Hemochromatosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Myeloproliferative disorders (myelodysplasia) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Other, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Please check any INFECTIONS conditions that are still active and/or for which you are taking medicationsCondition DiagnosedYear(s) of DiagnosisCondition ActiveTake Medications (past year)Currently Take Medications Medication name(s)Medications work wellCondition no longer active/resolved FORMCHECKBOX Mononucleosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Lyme disease, Specify type: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX HIV/AIDS FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Fungal disease (not including fungus skin infection) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Chronic parasitic infection FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Tuberculosis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Syphilis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Subacute bacterial endocarditis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Sepsis, ever FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Sepsis in the past 12 weeks FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Osteomyelitis FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX FORMCHECKBOX Other, specify: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not applicable FORMCHECKBOX Treatments received for any immune disorders? FORMCHECKBOX Yes FORMCHECKBOX No GENERAL INSTRUCTIONSImportant note: Some of the data elements on this form are considered Core (as specified by an asterisk) and are required by all ME/CFS studies to collect. The remaining data elements are considered Exploratory (i.e., non-Core) and should only be collected if the research team considers them appropriate for their study.*Element is classified as Core**Element is classified as Supplemental – Highly RecommendedSPECIFIC INSTRUCTIONSPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module. ................
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