Health Appraisal Questionnaire Male Version



Health Appraisal Questionnaire Male VersionVerbatim QuestionCoding and commentsDo you have:Frequent stuffy or watery nose, sneezing1=yes 2=noAn allergy to any medications1=yes 2=noAsthma or notice yourself wheezing1=yes 2=noChronic bronchitis or emphysema1=yes 2=noA frequent cough for any reason1=yes 2=noShortness of breath1=yes 2=noHave you ever:Coughed up blood (coughed not vomited)1=yes 2=noBeen treated for TB or Coccidomycosis (Valley Fever)1=yes 2=noHad a positive TB test1=yes 2=noBeen a smoker1=yes 2=noIf now a smoker how many cigarettes a dayHad lung cancer1=yes 2=noDo you chew tobacco1=yes 2=noHave you ever had, or ever been told you have:High blood pressure1=yes 2=noTo take blood pressure medicine1=yes 2=noA heart attack (coronary)1=yes 2=noTo take medicine to lower your cholesterol1=yes 2=noDo you get:Pains or heavy pressure in your chest with exertion1=yes 2=noDo you use nitroglycerin1=yes 2=noEpisodes of fast heart beats or skipped beats1=yes 2=noOther heart problems1=yes 2=noNocturnal leg cramps1=yes 2=noLeg pains from rapid or uphill walking, stairs1=yes 2=noDo you have:Varicose veins1=yes 2=noAny skin problems1=yes 2=noAre you troubled by:Abdominal (stomach) pains1=yes 2=noFrequent indigestion or heartburn1=yes 2=noConstipation1=yes 2=noFrequent diarrhea, loose bowels1=yes 2=noHas there been a definite change:In the pattern or regularity of your bowel movements in the last year1=yes 2=noAre you a vegetarian1=yes 2=noHave you ever had, or been told you have:An ulcer1=yes 2=noVomited blood1=yes 2=noBlack tar-like bowel movements1=yes 2=noGallstones, gallbladder problems1=yes 2=noYellow jaundice, hepatitis, or any liver trouble1=yes 2=noDefinite change in your weight in recent months1=yes 2=noAre you troubled by:Frequent headaches1=yes 2=noAttacks of dizziness1=yes 2=noHave you everHad seizures, convulsions, fits1=yes 2=noFainted or lost consciousness for no obvious reason1=yes 2=noTemporarily lost control of a hand or foot (paralysis)1=yes 2=noHad a stroke or “small stroke”1=yes 2=noBeen temporarily unable to speak1=yes 2=noAre you troubled by:Frequent back pain1=yes 2=noPain or swelling in your joints1=yes 2=noHave you ever:Broken any bones1=yes 2=noFrequently worried about being ill1=yes 2=noBeen troubled as a result of being more sensitive than most people1=yes 2=noHad special circumstances in which you find yourself panicked1=yes 2=noHad reason to fear your anger getting out of control1=yes 2=noHave you had, or do you have:Any problems with your urinary tract (kidney, bladder)1=yes 2=noLoss of control of your urine1=yes 2=noPain or burning when you urinate1=yes 2=noBlood in your urine1=yes 2=noTrouble starting the flow of urine1=yes 2=noTo get up repeatedly at night to urinate1=yes 2=noDischarge from your nipples1=yes 2=noHave you ever been treated for or told you had:Any venereal disease1=yes 2=noDiabetes1=yes 2=noTo take medicine for diabetes1=yes 2=noThyroid disease1=yes 2=noCancer1=yes 2=noHave you ever had or do you now have:Radiation therapy1=yes 2=noTrouble refusing requests or saying “No”1=yes 2=noHallucinations (seen, smelled, or heard things that were not really there1=yes 2=noTrouble falling asleep or staying asleep1=yes 2=noTiredness, even after a good night’s sleep1=yes 2=noCrying spells1=yes 2=noDepression or “feel down in the dumps”1=yes 2=noMuch trouble with nervousness1=yes 2=noDo you:Sometimes drink more than is good for you1=yes 2=noUse street drugs1=yes 2=noHave you ever:Been raped, or sexually molested as a child1=yes 2=noAre you:Currently sexually active with a partner1=yes 2=noSatisfied with your sex life1=yes 2=noConcerned you are at risk for AIDS1=yes 2=noPlease tell us:In the past year, about how many visits to a doctor have youmade.How far have you gone in school.Are you married1=yes 2=noHow many times have you been married.Are you now having serious or disturbing problems with your:Marriage1=yes 2=noFamily1=yes 2=noDrug usage1=yes 2=noJob1=yes 2=noFinancial matters1=yes 2=noHave you ever had coronary artery surgery1=yes 2=noApproximate yearRange: 1-96.Did you have a blood transfusion between 1978and 19851,2,.Do you feel you need any immunizations1,2,.Are you retired1=yes 2=noHave members of your family died before the age of 65?1=yes 2=noAre there diseases which a number of family members have had?1=yes 2=noAre there any unusual illnesses in your family you didn’t list previously?1=yes 2=noHas a parent, brother, or sister developed coronary (heart) disease before age 60?1=yes 2=noDo you have an identical twin?1=yes 2=noPlease fill in the circle that you think best describes your current state of health1=excellent 2=good 3=fair 4=poorDo you regularly use seat belts in a car?1=yes 2=noPlease fill in the circle that best describes your stress level:1=high 2=medium 3=low ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download