Health Analyzer Questionnaire

Height and Weight

Height:  
  feet  
  inches  
Weight:    lbs.

Current & Past Smoking/Tobacco use

Check each tobacco product that you have EVER smoked or used:  
How long has it been since you last smoked a cigarette?  
On average, how many cigarettes per day do/did you smoke?  
How long has it been since you last smoked a cigar?  
On average, how many cigars per day do/did you smoke?  
How long has it been since you last smoked a pipe?  
How long has it been since you last used chewing tobacco?  
How long has it been since you last used nicotine patches or gum?  

Blood Pressure

Have you ever been treated for or taken medication for high blood pressure?      
What is your systolic pressure?  
What is your diastolic pressure?  
When were you last treated for high blood pressure?   If currently taking blood pressure medication, How long has your blood pressure been successfully controlled by medication?  

Cholesterol

Have you ever been treated for or taken medication for high cholesterol?      
What is your cholesterol level?  
What is your HDL ratio?  
When were you last treated for high cholesterol?   If currently taking cholesterol medication, How long has your cholesterol been successfully controlled by medication?  

Driving

Have you ever had a drivers license?    
      if you answer No, driving record is ignored
Have you ever been convicted of drunken driving (DUI/DWI)?    
  How long since the most recent conviction for drunken driving (DUI/DWI)?  
Have you ever been convicted of reckless driving?    
  How long since the most recent conviction for reckless driving?  
Has your license ever been revoked or suspended?    
  How long since the most recent conviction resulting in a revoked or suspended license?  
Have you ever had more than one accident?    
  Not counting your last accident, how long has it been since the accident which preceeded your last?  
Please indicate the total number of moving violations/tickets (ie. not parking tickets) that you have received in each of the last time periods:  
during the last 6 months:  
during the last last year, more than 6 months:  
during the last 2 years, more than 1 year:  
during the last 3 years, more than 2 year:  
during the last 5 years, more than 3 year:  

Family History

Family related deaths:  
Please indicate the total number of family members (parents or siblings)
who have died from cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:  
Youngest Family Death Due to Disease (father, mother, brother or sister):  
Please indicate the age of the youngest family member who died due the named illnesses which follow:   Please indicate the age when this person first contracted any of the named illnesses:  
Was this person a parent?    
Please check off any and all illnesses which this family member experienced:    
2nd Youngest Family Death Due to Disease (father, mother, brother or sister):  
Please indicate the age of the 2nd youngest family member who died due the named illnesses which follow:   Please indicate the age when this person first contracted any of the named illnesses:  
Was this person a parent?    
Please check off any and all illnesses which this family member experienced:    
3rd Youngest Family Death Due to Disease (father, mother, brother or sister):  
Please indicate the age of the 3rd youngest family member who died due the named illnesses which follow:   Please indicate the age when this person first contracted any of the named illnesses:  
Was this person a parent?    
Please check off any and all illnesses which this family member experienced:    
Family related occurance of disease:   Not including those who died, please indicate the total number of family members (parents or siblings) who have contracted cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:  
Youngest Family Member to contract one of the following diseases (father, mother, brother or sister):  
Please indicate the age when this person first contracted any of the named illnesses:  
Was this person a parent?    
Please check off any and all illnesses which this family member experienced:    
2nd Youngest Family Member to contract one of the following diseases (father, mother, brother or sister):
Please indicate the age when this person first contracted any of the named illnesses:  
Was this person a parent?    
Please check off any and all illnesses which this family member experienced:    
3rd Youngest Family Member to contract one of the following diseases (father, mother, brother or sister):
Please indicate the age when this person first contracted any of the named illnesses:  
Was this person a parent?    
Please check off any and all illnesses which this family member experienced:    

Substance Abuse

Have you ever been treated for alcohol abuse?    
The number of years since treatment:  
Have you ever been treated for drug abuse?    
The number of years since treatment:  
Powered by COMPULIFE®



Copyright © 1999 - TERM4SALE®, Inc.
 
All rights reserved  |  Terms of Use  |  Privacy Policy