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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