Date Medical History Taken (M M/D D/Y Y Y Y): Does the participant/subject have a history of any medical problems/conditions in the following body systems? Yes No (leave rest of form blank) Enter all significant medical history items, including surgeries, EXCEPT the problem/condition that is the focus of this study. Use only one line per description. *Use BODY SYSTEM categories for medical history table: Constitutional symptoms (e.g., fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Table of subject’s/participant’s medical history items Body System Medical History Term (one item per line) Start Date (mm/dd/yyyy) Ongoing? End Date (mm/dd/yyyy) Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site Data to be entered by site Data to be entered by site Data to be entered by site Yes No Data to be entered by site The following interview questions can be used to help make sure a complete medical history is documented.
Unknown If YES, migraine(s) with aura: Yes No Unknown Carotid stenosis: Yes No Unknown Carotid endarterectomy: Yes No Unknown If YES, indicate location: Left side Right side Both Unknown Carotid artery stenting: Yes No Unknown If YES, indicate location: Left side Right side Both Unknown Seizure episode: Yes No Unknown Epilepsy/ Seizure disorder: Yes No Unknown Central nervous system infection: Yes No Unknown Dementia: Yes No Unknown Current clinical depression: Yes No Unknown Depressive disorder diagnosis: Yes No Unknown If YES, age experienced first depressive episode/ diagnosed with depression (years): Current clinical anxiety: Yes No Unknown Anxiety disorder diagnosis: Yes No Unknown Psychotic disorder: Yes No Unknown
Other, specify: Date of most recent cardiac surgery (M M/D D/Y Y Y Y): Artificial valve: Yes No Unknown If YES, indicate type: Biological/ Tissue valve Mechanical/ Non-tissue valve Valvuloplast Unknown type of valve Coronary stent or PTCA: Yes No Unknown Congestive heart failure: Yes No Unknown Congenital heart disease: Yes No Unknown Cardiac catheritization: Yes No Unknown If YES, indicate recency: ≤ 2 weeks > 2 weeks ago Unknown Peripheral arterial disease: Yes No Unknown Hypertension: Yes No Unknown If YES, age hypertension first diagnosed (years): Diabetes mellitus: Yes No (Skip to 37) Unknown (Skip to 37) Age diabetes first diagnosed (years): Complications of diabetes (choose all that apply): Nephropathy Neuropathy Retinopathy Other, specify: None of the above Treatment for diabetes (choose all the apply): Diet Oral medication Insulin None of the above High blood cholesterol / Hypercholesterolemia: Yes No Unknown If YES, indicate treatment(s): (choose all the apply) Diet Statins
Other medicines None of the above Hypertriglyceridemia: Yes No Unknown Cancer: Yes No (Skip to 40) Unknown (Skip to 40) Type(s) of cancer: Brain Breast Colorectal Endometrial Esophagus Lung Prostate Renal (kidney) Skin Other, specify: Did you receive head or neck radiation to treat the cancer? Yes No Unknown Infection within two weeks: Yes No Unknown If YES, indicate type(s) (choose all that apply): Respiratory infection Urinary tract infection (UTI) Cellulitis Sepsis Otitis media Mastoiditis Viral gastroenteritis Fever lasting > 48 hours Other infection, specify: Sickle cell anemia: Yes No Unknown If YES, are blood transfusions used as treatment? Yes No Unknown Hypercoagulable disorder: Yes No Unknown If YES, specify type: Bleeding disorder: Yes No Unknown If YES, specify type: Lupus: Yes No Unknown Other connective tissue disease: Yes No Unknown If YES, specify type: Sleep apnea: Yes No Unknown If YES, specify type: