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:

First

Last

Email:

Address:

Date of Birth:

Sex:

Male

Female

Race (choose all that apply):

How would you rate your health today? (check one):

Have you recently been diagnosed with an acute infection (eg. influenza, sinus infection, COVID-19, UTI, etc.)?

Yes

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

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

Polyp?

Yes

Women only

Mammogram

Most recent date/where:

Abnormal?

Yes

Pap Smear

Most recent date/where:

Abnormal?

Yes

Bone Density Test

Most recent date/where:

Abnormal?

Yes

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

Hip Fracture

Hip Fracture When

Now

Past

Hip Fracture Comments

Irritable Bowel Syndrome

Irritable Bowel Syndrome When

Now

Past

Irritable Bowel Syndrome Comments

Kidney Disease / Failure

Kidney Disease / Failure When

Now

Past

Kidney Disease / Failure Comments

Kidney Stones

Kidney Stones When

Now

Past

Kidney Stones Comments

Liver Disease

Liver Disease When

Now

Past

Liver Disease Comments

Migraine Headaches

Migraine Headaches When

Now

Past

Migraine Headaches Comments

Osteoporosis

Osteoporosis When

Now

Past

Osteoporosis Comments

Pneumonia

Pneumonia When

Now

Past

Pneumonia Comments

Prostate (enlargement)

Prostate (enlargement) When

Now

Past

Prostate (enlargement) Comments

Prostate (nodules)

Prostate (nodules) When

Now

Past

Prostate (nodules) Comments

Seizure / Epilepsy

Seizure / Epilepsy When

Now

Past

Seizure / Epilepsy Comments

Skin Condition (Eczema)

Skin Condition (Eczema) When

Now

Past

Skin Condition (Eczema) Comments

Skin Condition (Psoriasis)

Skin Condition (Psoriasis) When

Now

Past

Skin Condition (Psoriasis) Comments

Skin Condition (Abnormal Moles)

Skin Condition (Abnormal Moles) When

Now

Past

Skin Condition (Abnormal Moles) Comments

Sleep Apnea

Sleep Apnea When

Now

Past

Sleep Apnea Comments

Stomach Ulcer

Stomach Ulcer When

Now

Past

Stomach Ulcer Comments

Stroke

Stroke When

Now

Past

Stroke Comments

Thyroid (Nodule)

Thyroid (Nodule) When

Now

Past

Thyroid (Nodule) Comments

Thyroid High (Overactive) / Hyperthyroidism

Thyroid High (Overactive) / Hyperthyroidism When

Now

Past

Thyroid High (Overactive) / Hyperthyroidism Comments

Thyroid Low (Underactive) / Hypothyroidism

Thyroid Low (Underactive) / Hypothyroidism When

Now

Past

Thyroid Low (Underactive) / Hypothyroidism Comments

Other (list)

Other (list) When

Now

Past

Other (list) Comments

SURGICAL & PROCEDURE HISTORY: Please check off any procedure or surgeries. List any abnormal finding, details or complications under comments.

No surgeries

Check box if you have never had any medical procedures or surgeries.

Surgical Procedure

Code

Year

Comments

Abdominal surgery

HX0004

Abdominal surgery Year

Abdominal surgery Comments

Angiogram (heart)

HX0541

Angiogram (heart) Year

Angiogram (heart) Comments

Angiogram (vascular)

HX0503

Angiogram (vascular) Year

Angiogram (vascular) Comments

Appendectomy (appendix removal)

HX0023

Appendectomy (appendix removal) Year

Appendectomy (appendix removal) Comments

Back surgery (lumbar)

HX0032

Back surgery (lumbar) Year

Back surgery (lumbar) Comments

Biopsy (location in comments)

HX0524

Biopsy (location in comments) Year

Biopsy (location in comments) Comments

Breast Biopsy

HX0043

Breast Biopsy Year

Breast Biopsy Comments

Breast surgery

HX0056

Breast surgery Year

Breast surgery Comments

Cataract surgery

HX0196

Cataract surgery Year

Cataract surgery Comments

Colonoscopy

HX0095

Colonoscopy Year

Colonoscopy Comments

Coronary Bypass

HX0526

Coronary Bypass Year

Coronary Bypass Comments

Coronary Stent

HX0243

Coronary Stent Year

Coronary Stent Comments

C-Section

C-Section Year

C-Section Comments

Echocardiogram (heart)

Echocardiogram (heart) Year

Echocardiogram (heart) Comments

EGD (Stomach Endoscopy)

HX0491

EGD (Stomach Endoscopy) Year

EGD (Stomach Endoscopy) Comments

Gallbladder Removal

HX0349

Gallbladder Removal Year

Gallbladder Removal Comments

Laparoscopic (HX0271)

Heart Surgery (other than coronary bypass checked above)

Heart Surgery (other than coronary bypass checked above) Year

Heart Surgery (other than coronary bypass checked above) Comments

Hip Surgery

HX0224

Hip Surgery Year

Hip Surgery Comments

Hysterectomy (partial, ovaries left)

Hysterectomy (partial, ovaries left) Year

Hysterectomy (partial, ovaries left) Comments

Hysterectomy (total, including ovaries)

HX0600

Hysterectomy (total, including ovaries) Year

Hysterectomy (total, including ovaries) Comments

Knee Surgery

HX0261

Knee Surgery Year

Knee Surgery Comments

LEEP (Cervix surgery)

HX0105

LEEP (Cervix surgery) Year

LEEP (Cervix surgery) Comments

Neck (Spine) surgery

HX0554

Neck (Spine) surgery Year

Neck (Spine) surgery Comments

Ovary Removal

HX0355

Ovary Removal Year

Ovary Removal Comments

Pulmonary Function Test

INT0015

Pulmonary Function Test Year

Pulmonary Function Test Comments

Sigmoidoscopy

HX0426

Sigmoidoscopy Year

Sigmoidoscopy Comments

Sinus Surgery

HX0427

Sinus Surgery Year

Sinus Surgery Comments

Stress Test (stress echo)

HX0433

Stress Test (stress echo) Year

Stress Test (stress echo) Comments

Stress Test (thallium/perfusion)

HX0294

Stress Test (thallium/perfusion) Year

Stress Test (thallium/perfusion) Comments

Stress Test (treadmill)

HX0191

Stress Test (treadmill) Year

Stress Test (treadmill) Comments

Tonsillectomy

HX00535

Tonsillectomy Year

Tonsillectomy Comments

Tubal ligation

HX00536

Tubal ligation Year

Tubal ligation Comments

Vasectomy

HX0356

Vasectomy Year

Vasectomy Comments

Other (list)

Other (list) Year

Other (list) Comments

FAMILY HISTORY

Adopted?

Yes

If adopted and you do not know your family history skip the Family History section and continue to Health Issues.

Indicate which relative has had the following diseases (parents, brothers & sisters are the most important). Write in number of siblings in appropriate boxes. *If some siblings are alive and some are deceased use the space to explain further.

Number of Sisters

Number of Brothers

Alive

Siblings Alive Notes

Deceased

Siblings Deceased Notes

Age currently or at death

Mother:

Father:

Sister(s):

Brother(s):

Mom’s Mom:

Mom’s Dad:

Dad’s Mom:

Dad’s Dad:

Siblings Age Notes:

Diseases & Conditions

Relatives

List age(s) at diagnosis if known and if this was the cause of death

No significant history known

No significant history known Relatives

Hypertension – high blood pressure

Hypertension – high blood pressure Relatives

Hypertension – high blood pressure Age/Outcome

Hyperlipidemia – high cholesterol

Hyperlipidemia – high cholesterol Relatives

Hyperlipidemia – high cholesterol Age/Outcome

Heart Attack, Angina (Coronary Artery Disease)

Heart Attack, Angina (Coronary Artery Disease) Relatives

Heart Attack, Angina (Coronary Artery Disease) Age/Outcome

Diabetes Type II (adult onset)

Diabetes Type II (adult onset) Relatives

Diabetes Type II (adult onset) Age/Outcome

Cancer, Breast

Cancer, Breast Relatives

Cancer, Breast Age/Outcome

Cancer, Colon

Cancer, Colon Relatives

Cancer, Colon Age/Outcome

Cancer, Prostate

Cancer, Prostate Relatives

Cancer, Prostate Age/Outcome

Osteoporosis

Osteoporosis Relatives

Osteoporosis Age/Outcome

Depression

Depression Relatives

Depression Age/Outcome

Alcoholism / Drug abuse

Alcoholism / Drug abuse Relatives

Alcoholism / Drug abuse Age/Outcome

Alzheimers

Alzheimers Relatives

Alzheimers Age/Outcome

Asthma

Asthma Age/Outcome

Autoimmune Disease

Autoimmune Disease Relatives

Autoimmune Disease Age/Outcome

Bleeding or Clotting Disorder

Bleeding or Clotting Disorder Relatives

Bleeding or Clotting Disorder Age/Outcome

Cancer, Lung

Cancer, Lung Relatives

Cancer, Lung Age/Outcome

Cancer, Ovarian

Cancer, Ovarian Relatives

Cancer, Ovarian Age/Outcome

Cancer, Other type

Cancer, Other type Relatives

Cancer, Other type Age/Outcome

Colon Polyp

Colon Polyp Relatives

Colon Polyp Age/Outcome

Diabetes Type I (childhood onset)

Diabetes Type I (childhood onset) Relatives

Diabetes Type I (childhood onset) Age/Outcome

Emphysema (COPD)

Emphysema (COPD) Relatives

Emphysema (COPD) Age/Outcome

Genetic Disorder (explain)

Genetic Disorder (explain) Relatives

Genetic Disorder (explain) Age/Outcome

Glaucoma

Glaucoma Age/Outcome

Heart Disease (CHF)

Heart Disease (CHF) Relatives

Heart Disease (CHF) Age/Outcome

Heart Disease (Other)

Heart Disease (Other) Relatives

Heart Disease (Other) Age/Outcome

Hepatitis B or C

Hepatitis B or C Relatives

Hepatitis B or C Age/Outcome

Hip Fracture

Hip Fracture Relatives

Hip Fracture Age/Outcome

Hypothyroidism / Thyroid Disease

Hypothyroidism / Thyroid Disease Relatives

Hypothyroidism / Thyroid Disease Age/Outcome

Kidney Disease

Kidney Disease Relatives

Kidney Disease Age/Outcome

Kidney Stones

Kidney Stones Relatives

Kidney Stones Age/Outcome

Macular Degeneration

Macular Degeneration Relatives

Macular Degeneration Age/Outcome

Stroke

Stroke Age/Outcome

Sudden Cardiac Death

Sudden Cardiac Death Relatives

Sudden Cardiac Death Age/Outcome

Other (list)

Other (list) Relatives

Other (list) Age/Outcome

HEALTH ISSUES

Tobacco Use

Smoke or smoked?

Never

Currently smoking

Former smoker

Tobacco type:

Cigarettes

Pipe

Cigar

If a current smoker, how many packs/day?

If a current smoker, how many years?

If a former smoker, when did you quit?

If a former smoker, approximately how many packs/day did you smoke?

If a former smoker, how many years did you smoke?

Other tobacco?

Snuff

Chew

Do you currently use?

Yes

Quit Date:

Are you ready to quit?

Yes

Exposure to second hand smoke?

Yes

Alcohol Use

Do you drink alcohol?

Yes

Number of drinks/week:

Alcohol type:

Beer

Wine

Liquor

How many times in a year have you had >3 drinks (for women) >4 drinks (for men) in a day?

Drug Use

Have you ever used recreational drugs?

Yes

If yes, which ones?

Quit which ones?

Ones used currently?

Sexual Activity

Are you sexually involved?

Sexual partner(s) is/are/have been/may be in future:

Male

Female

Other (ADL)

Military Service?

Yes

Blood Transfusion?

Yes

Exposure to toxic chemicals at work?

Yes

Exposure to toxic chemicals doing hobbies?

Yes

Diet

Do you follow a special diet? Do you follow a special diet?

Exercise

Do you exercise regularly?

Yes

What kind of exercise?

How long (minutes)?

How often?

Do you use a helmet for recreational activities? (e.g. bike, skateboard, ski)

Do you use seatbelts consistently?

Yes

In the past 2 weeks have you been feeling down, depressed or hopeless?

Yes

Do you have little interest or pleasure in doing things?

Yes

SAFETY

Does your home have a working smoke detector?

Yes

Do you have guns in your home?

Yes

Are they locked up & ammo stored separately?

Yes

Have you or any family members ever been hurt, insulted, threatened or screamed at?

Yes

SOCIAL DOCUMENTATION

Name you prefer we use when contacting you (nickname, first, or last with Mr, Mrs, Ms, etc):

Country of birth:

Who lives at home with you?

No one

Spouse/partner

ChildrenChildren

Pets (what type)Pets (what type)

Other (roommates, extended family, etc)Other (roommates, extended family, etc)

Please list your interests, hobbies, group involvement, volunteer work, and/or travel outside of country in the past 6 months:

SOCIOECONOMIC

Occupation (or prior occupation):

Employer:

If you are not currently working, you are: If you are not currently working, you are:

Marital status:

Spouse/partner’s name:

Number of children:

Ages (if minors):

Number of grandchildren:

Number of great grandchildren:

Education: Education:

MEDICAL FORMS

Please check any of the following forms you have completed:

Advance Directive for Health Care (ADHC)

Durable Power of Attorney (DPA) for healthcare decisions

Living Will

POLST (Physician Orders for Life Sustaining Therapy)

Know about these or have the forms but have not completed them

Don’t know what these are

WOMEN’S HEALTH HISTORY

Total number of pregnancies:

Number of births:

Number of miscarriages:

Number of abortions:

Age at beginning of periods (menstruation):

Age at end of periods (menopause/hysterectomy), if applicable:

Do you have concerns about your periods or menopause you’d like to discuss?

Yes

If you are having periods, how often do they occur (in days)?

How long do they last (in days)?

If you are human, leave this field blank.

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