Form 01: Contact Record/Locator Form



|SECTION B: PATIENT IDENTIFYING INFORMATION – Obtained from patient at time of consent |

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|Has the patient or authorized representative signed informed consent? |

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|Yes | |No |STOP: PLEASE HAVE PATIENT or authorized representative COMPLETE INFORMED CONSENT |

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|Date of informed consent: |

|What is the subject’s date of birth? |

|Subject’s gender: | | Male | | Female | |

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|Marital Status: |

| |Single | | |Married | | |Separated |

| |Divorced | | |Widowed | | |Partner |

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|Education Level: |

| |Less than High School | | |Some High School |

| |GED | | |High School Graduate |

| |Some College | | |College Graduate |

| |Post Graduate Degree | | | |

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|Occupation: |

| |Work outside the home | | |Homemaker |

| |Retired | | |Disabled |

| |Other | |

|If you work outside the home, what is your occupation? | |

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|Do you consider your ethnicity to be Hispanic or Latino? | Yes | No | Refused |

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|For this question on racial background, you may select one or more choices. Do you consider yourself to be... (check all that apply): |

| |White/Caucasian | | |Black/African American |

| |Asian | | |Native Hawaiian/Pacific Islander |

| |American Indian/Alaskan Native |

| |Other (Please specify): | |

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|If there is more than one response for above, which do you consider to be your primary racial background? (choose only one) |

| |White/Caucasian | | |Black/African American |

| |Asian | | |Native Hawaiian/Pacific Islander |

| |American Indian/Alaskan Native |

| |Other (Please specify): | |

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|Past Medical History: |

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|Condition |Present | |

|Diabetes, if yes, please specify child or adult onset | Yes | No | Child | Adult |

|High Blood Pressure | Yes | No | |

|Seizures/Epilepsy | Yes | No | |

|Blood Transfusions | Yes | No | |

|Cancer: if yes, what type? | Yes | No | |

|Heart Disease: if yes, what type? | Yes | No | |

|Lung Disease: if yes, what type? | Yes | No | |

|Kidney Disease: if yes, what type? | Yes | No | |

|Thyroid Disease: if yes, what type? | Yes | No | |

|Liver Disease: if yes, what type? | Yes | No | |

|Emotional Problems/Depression: if yes, please explain? | Yes | No | |

|Weight Loss: if yes, please specify weight loss in pounds? | Yes | No | |

|Weight Gain: if yes, please specify weight gain in pounds? | Yes | No | |

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|For Women Only: |

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|Currently having monthly periods? | Yes | No | Post Menopausal |Date of last menstrual period | |

|Are you pregnant? | Yes | No |If yes, what is your due date? | |

|Are you breastfeeding? | Yes | No | |

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|Past Surgical History: | Not Applicable |

|Please describe your past surgical history. |

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|Type | |Date |

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|Past Hospitalizations: | Not Applicable |

|Please describe your past hospitalizations for non-surgical reasons. |

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|Reason | |Date |

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|Review of Health Problems: (Please check all that you have experienced in the past 3 months) |

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|System |Health Problems |

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|Skin | Easy Bruising | Rash |

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|Lymph Nodes | Tender | Enlarged (Specify Location Below) |

| |Lymph Nodes Enlarged (Location) | |

| | Groin | Armpits | Neck | Other |

| |If "Other", Specify location | |

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|Head | Dizziness | Headache |

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|Eyes | Blurred Vision | Wears Glasses | Wears Contacts |

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|Ears | Ringing in Ears | Sensitivity to Loud Noises | Difficulty Hearing |

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|Nose | Runny Nose | Congestion | Sensitivity to Smell | Allergies |

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|Mouth | Tooth Sensitivity | Bleeding | Gums | Bad Breath | Dry | Ulcers |

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|Throat | Sore | Scratchy |

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|Neck | Thyroid Problems | |

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|Breasts | Tender | Surgically Augmented/Altered |

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|Respiratory | Cough | Shortness of Breath |

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|Cardiovascular | Heaviness | Pain | Palpitations | Pain in Legs that is relieved with stopping activity |

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|Gastrointestinal | Cramps | Diarrhea | Bloating | Stomach aches |

| | Pain | Constipation | Gas | |

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|Genitourinary | Painful Intercourse | Vaginal Discharge | Vaginal Itching | Urinary Urgency |

| | Urinary Burning | Getting up at night to urinate more than 3 times. |

| |Genitourinary (Sexually Transmitted Disease) |

| | STD Current |STD Current, Specify Type | |

| | STD Past |STD Past, Specify Type | |

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|Review of Health Problems: (Continued) |

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|Musculoskeletal | Muscle Cramping | Stiff Joints | Joint Redness |

| | Muscle Weakness | Aching Joints | Joint Swelling |

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|Nervous system | Hypersensitivity to Touch | Tingling | Hot | Difficulty Walking |

| | Burning Sensations |Burning Sensation, Specify Location | |

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|Endocrine | Fatigue | Chills | Sweating |

| | Unintentional Weight Loss | Unintentional Weight Gain |

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|Psychiatric | Obsessive Activities | Anxiety | Depression Current | Depression Past |

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|Sleep Problems | Difficulty Falling Asleep | Difficulty Staying Asleep | Awakening Feeling Un-refreshed |

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|Allergies: |

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|Do you have any Allergies to Medicine(s)? |Yes (If "Yes", please describe below) |No |

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|Medication | |Reaction |

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|Tobacco Use: |

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|Do you use Tobacco? | Yes | No |

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|Cigarettes? | Current | Past |Year Quit? | |

| |Number of cigarettes per day? | | |

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|Cigars? | Current | Past |Year Quit? | |

| |Number of cigars per day? | | |

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|Pipes? | Current | Past |Year Quit? | |

| |Number of pipes per day? | | |

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|Chewing Tobacco? | Current | Past |Year Quit? | |

| |Number of times used per day? | | |

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|Drug Use: |

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|Have you used any IV drugs / "street" drugs (cocaine, marijuana)? | Yes | No |

| |If "Yes", When? | |If "Yes", What drug(s)? | |

| |Do you currently use it? | Yes | No | | |

| |How often? | Daily | Weekly | Monthly | Occasionally |

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|Alcohol Use: |

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|How many drinks do you usually have a week? | | |

|Have you ever felt that you should cut down on your drinking? | Yes | No |

|Have people annoyed you by criticizing your drinking? | Yes | No |

|Have you ever felt bad or guilty about drinking? | Yes | No |

|Have you ever taken a drink the first thing in the morning to steady your nerves or to get rid of a hangover? | Yes | No |

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|Family History |

|Please list the relationship next to any of the conditions below that a blood relative has had. |

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|Condition |Relationship (i.e. father, mother, sister, brother, son, daughter, etc.) |

|Heart attack | |

|Emphysema | |

|Diabetes | |

|Rheumatoid Arthritis | |

|High blood pressure | |

|Crohn's Disease | |

|Asthma | |

|Colitis | |

|Lupus | |

|Colon cancer | |

|Breast cancer | |

|Allergies | |

|Stroke | |

|Tuberculosis | |

|Anemia | |

|Seizure or Epilepsy | |

|Alcoholism | |

|Cirrhosis | |

|Irritable Bowel Syndrome (spastic colon) | |

|Easy bleeding/bruising | |

|Thyroid problem (goiter) | |

|Cholesterol problem | |

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|Do any other conditions run in your family? | Yes | No |

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| |If Yes, please list: | |

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|Investigator/Coordinator Signature: | |

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//MM/DD/YYYY

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