Sample Repository Questionnaire Sample Repository Questionnaire Your answers on this form will provide PanoHealth an accurate history of your medical conditions. It will be stored de-identified along with your donated blood sample in the repository. Please complete all sections. It is long because this comprehensive data is best for utility in future research. If you cannot remember specific details, please provide your best guess. If you are uncomfortable with any question, do not answer it. Thank you! Name: * Name: First First Last Last Email: * Address: * Date of Birth: * Sex: * Male Female Race (choose all that apply): * American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other How would you rate your health today? (check one): * ExcellentGoodFairPoor Have you recently been diagnosed with an acute infection (eg. influenza, sinus infection, COVID-19, UTI, etc.)? * Yes No What: * When: * MEDICATIONS: Please list all prescriptions and non-prescription medications. This includes vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc.) No Medications: Check box if you do not take any prescription or over the counter medications Medication Dose (e.g. mg/pill) How many times per day Medication 1 Dose (e.g. mg/pill) 1 How many times per day 1 Medication 2 Dose (e.g. mg/pill) 2 How many times per day 2 Medication 3 Dose (e.g. mg/pill) 3 How many times per day 3 Medication 4 Dose (e.g. mg/pill) 4 How many times per day 4 Medication 5 Dose (e.g. mg/pill) 5 How many times per day 5 Medication 6 Dose (e.g. mg/pill) 6 How many times per day 6 Medication 7 Dose (e.g. mg/pill) 7 How many times per day 7 Medication 8 Dose (e.g. mg/pill) 8 How many times per day 8 ALLERGIES or intolerance to medications? * Yes No If yes, to what & what reaction? * IMMUNIZATIONS: Enter year (if known) of any vaccinations you have had. Tetanus (Td): With Pertussis (Tdap): Varicella (Chicken Pox) shot or illness: Pneumovax (pneumonia): Influenza (flu shot): Hepatitis A: Hepatitis B: MMR: Meningitis: Zostavax (shingles): HPV: HEALTH MAINTENANCE SCREENING TESTS Lipid (cholesterol) Date: Result, if known: Select One: Sigmoidoscopy Colonoscopy Date (year): Abnormal? Yes No Polyp? Yes No Women only Mammogram Most recent date/where: Abnormal? Yes No Pap Smear Most recent date/where: Abnormal? Yes No Bone Density Test Most recent date/where: Abnormal? Yes No PERSONAL MEDICAL HISTORY: Do you have now or have you had (past) any of the following conditions? No medical illnesses Check box if you have no history of significant medical illnesses. Condition When Comments Alcohol / Drug abuse Alcohol / Drug abuse When Now Past Alcohol / Drug abuse Comments Allergy (Hay Fever) Allergy (Hay Fever) When Now Past Allergy (Hay Fever) Comments Anemia Anemia When Now Past Anemia Comments Anxiety Anxiety When Now Past Anxiety Comments Arthritis (Rheumatoid) Arthritis (Rheumatoid) When Now Past Arthritis (Rheumatoid) Comments Arthritis (Osteoarthritis) Arthritis (Osteoarthritis) When Now Past Arthritis (Osteoarthritis) Comments Asthma Asthma When Now Past Asthma Comments Bladder / Kidney Problems Bladder / Kidney Problems When Now Past Bladder / Kidney Problems Comments Blood Clot (leg) Blood Clot (leg) When Now Past Blood Clot (leg) Comments Blood Clot (lung) Blood Clot (lung) When Now Past Blood Clot (lung) Comments Blood Transfusion Blood Transfusion When Now Past Blood Transfusion Comments Breast Lump (benign) Breast Lump (benign) When Now Past Breast Lump (benign) Comments Cancer Breast Cancer Breast When Now Past Cancer Breast Comments Cancer Colon Cancer Colon When Now Past Cancer Colon Comments Cancer Ovarian Cancer Ovarian When Now Past Cancer Ovarian Comments Cancer Prostate Cancer Prostate When Now Past Cancer Prostate Comments Cancer Other Type Cancer Other Type When Now Past Cancer Other Type Comments Cataracts Cataracts When Now Past Cataracts Comments Chicken Pox Chicken Pox When Now Past Chicken Pox Comments Colon Polyp Colon Polyp When Now Past Colon Polyp Comments Coronary Artery Disease Coronary Artery Disease When Now Past Coronary Artery Disease Comments Depression Depression When Now Past Depression Comments Diabetes (adult onset) Diabetes (adult onset) When Now Past Diabetes (adult onset) Comments Diabetes (childhood onset) Diabetes (childhood onset) When Now Past Diabetes (childhood onset) Comments Diverticulosis Diverticulosis When Now Past Diverticulosis Comments Emphysema (COPD) Emphysema (COPD) When Now Past Emphysema (COPD) Comments Fractures (broken bones) Fractures (broken bones) When Now Past Fractures (broken bones) Comments Gallbladder Disease Gallbladder Disease When Now Past Gallbladder Disease Comments Gastroesophageal Reflux (Heartburn/GERD) Gastroesophageal Reflux (Heartburn/GERD) When Now Past Gastroesophageal Reflux (Heartburn/GERD) Comments Glaucoma Glaucoma When Now Past Glaucoma Comments Gout Gout When Now Past Gout Comments Gynecological Conditions (Endometriosis) Gynecological Conditions (Endometriosis) When Now Past Gynecological Conditions (Endometriosis) Comments Gynecological Conditions (Fibroids) Gynecological Conditions (Fibroids) When Now Past Gynecological Conditions (Fibroids) Comments Gynecological Conditions (Other) Gynecological Conditions (Other) When Now Past Gynecological Conditions (Other) Comments Heart Attack Heart Attack When Now Past Heart Attack Comments Hepatitis – Type A Hepatitis – Type A When Now Past Hepatitis – Type A Comments Hepatitis – Type B Hepatitis – Type B When Now Past Hepatitis – Type B Comments Hepatitis – Type C Hepatitis – Type C When Now Past Hepatitis – Type C Comments Hepatitis – Other Hepatitis – Other When Now Past Hepatitis – Other Comments High Blood Pressure High Blood Pressure When Now Past High Blood Pressure Comments High Cholesterol High Cholesterol When Now Past High Cholesterol Comments If you are human, leave this field blank. 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