T.W.U. Institute for Women's Health Pioneer Project

Year 1 Medical History Questionnaire
Personal Medical History

Section 3: Review of Systems


Please indicate whether you have had a significant problem with any of the symptoms or conditions listed below. If it is a problem that has happened more than once, mark "recurring" as well as all ranges of years in which it happened.

19. PULMONARY
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Chronic cough or phlegm
Wheezing
Tuberculosis
Pulmonary embolus
Asthma
Bronchitis
Pneumonia
Emphysema
Coughed up blood
Unexplained shortness of breath
Lung cancer
 
20. MUSCULOSKELETAL
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Chronic joint or muscle pain
Low back pain
Swollen/stiff joints
Gout
Herniated disk
Knee replacement
Hip replacement
Osteoarthritis
Rheumatoid arthritis
Arthritis, type unknown
Scoliosis
Spine fractures
Wrist fractures
Hip fractures
Ankle fractures
Rib fractures
Upper arm fractures
Skull fractures
 
21. HEART/VASCULAR
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Chest pain or pressure (Angina)
Heart attack
Heart failure
Rapid or irregular heartbeats
Fainting or light-headedness
High blood pressure
Rheumatic fever
Calf pain with exercise
Varicose veins
Phlebitis
Stroke
Transient Ischemic Attack
High blood cholesterol
High blood triglycerides
Coronary bypass or angioplasty
Carotid Endarterectomy
Peripheral artery disease or claudication of legs (not varicose veins)
Surgery for varicose veins
Congenital heart defects
 
22. HEMATOLOGY
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Anemia
Blood clotting deficiency
Enlarged or swollen lymph nodes
Previous blood transfusion
High blood calcium
HIV
Mononucleosis
Leukemia
Hepatitis: Type A B C
Sickle Cell/Sickle Cell Trait