Personal Medical History Section 2

Year 1 Medical History Questionnaire
Personal Medical History
Section 2: Medical Screenings Diagnostic Studies

10. Mark any of the procedures you've had in the past.

	TEST		YEAR
	Physical exam	YES NO Don't Know
	Rectal exam	YES NO Don't Know
	Stool occult blood exam	YES NO Don't Know
	Blood pressure check	YES NO Don't Know
	Breast exam by clinician	YES NO Don't Know
	Exam by eye doctor	YES NO Don't Know
	Skin cancer screening	YES NO Don't Know
	Thyroid functioning test (TSH)	YES NO Don't Know
	HIV test	YES NO Don't Know

11. In how many months did you practice breast-self examination in the past year?

	0	1	2-3	4-6	7-11	12+	Not Answered

12. Have you ever had any of these procedures or injections at any site? (mark any that apply)

	Breast implant	Silicone injection	Collagen injection	Paraffin injection

13. Check which of the following diagnostic studies you have had in the past.

	TEST		YEAR
	Mammogram	YES NO Don't Know
	Breast Biopsy	YES NO Don't Know
	ECG (Electrocardiogram)	YES NO Don't Know
	Treadmill Stress Test	YES NO Don't Know
	Ultrasound examination of the heart	YES NO Don't Know
	X-ray exam of stomach (Upper GI Series)	YES NO Don't Know
	X-ray exam of large intestine (Barium Enema)	YES NO Don't Know
	Proctoscopy or sigmoidoscopy (Examination of the lowest part of the colon and rectum with a rigid tube)	YES NO Don't Know
	Colonoscopy (Examination of the colon with a long flexible tube)	YES NO Don't Know
	Bone density testing	YES NO Don't Know

14. Have you ever had a TB skin test?				YES NO Don't Know

	14.1 If yes, what were the results?	Positive Negative Not known

	14.2 If positive, did you complete treatment?	yes no not known