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PERSONAL HEALTH INFORMATION
Have you ever been told by your doctor that you have or have had any of the following illnesses or conditions:
High Blood Pressure - A serious condition that can lead to coronary heart disease
(also called coronary artery disease), heart failure, stroke, kidney failure, and other health problems. "Blood pressure" is the force of blood pushing
against the walls of the arteries as the heart pumps blood. If this pressure rises and stays high over time, it can damage the body in many ways.
High Cholesterol - Cholesterol is a waxy substance that's found in the fats
(lipids) in your blood. While your body needs cholesterol to continue building healthy cells, having high cholesterol can increase your risk of heart
disease. When you have high cholesterol, you may develop fatty deposits in your blood vessels. Eventually, these deposits make it difficult for enough
blood to flow through your arteries. Your heart may not get as much oxygen-rich blood as it needs, which increases the risk of a heart attack. Decreased
blood flow to your brain can cause a stroke.
Diabetes - Includes either Type 1 (childhood onset) or Type 2 (adult onset) but not gestational
diabetes (diabetes during pregnancy only). Diabetes is sometimes simply referred to as “sugar” or “sugar diabetes”.
Stroke/TIA - Stroke is sometimes called a brain attack because of its similarity to a heart
attack. Stroke includes transient ischemic attacks (TIA’s,
which are sometimes referred to as “mini strokes”).
Coronary Heart Disease
- Includes recurring angina
pectoris, myocardial infarction or
coronary insufficiency. If you have
had angioplasty or a stent placed in an artery of your heart, then you have heart disease.
Other Cardiovascular Disease - Includes claudications, peripheral vascular or artery
disease (PVD or PAD), aneurism, or carotid atherosclerosis.
Congestive Heart Failure - Congestive heart failure (CHF), or heart failure, is a condition in
which the heart can't pump enough blood to the body's other organs. It often follows coronary heart disease, diabetes, or valve disease.
Valve Disease or Heart Murmur - A damaged or poorly functioning heart valve can cause a small
sound or murmur through a stethoscope. The cause can either be congenital (that is, since birth) or can be brought on by an infection of the heart later
in life. The most common valve affected is the mitral valve.
Left Ventricular Hypertrophy - An enlargement of the heart, specifically the left
ventricle. Generally, it is the result of an overworked heart, usually due to high blood pressure.
Atrial Fibrillation - Atrial fibrillation is a rapid, uncoordinated beating of the
heart's upper chambers.
FAMILY HISTORY
Have any of your blood relatives, living or dead, ever been told by their doctor that they have or had any of the following
conditions:
Coronary Heart Disease (CHD) - Father or brother before age 55 (and/or) mother or sister
before age 65.
Diabetes - Mother, father, sister, brother, daughter or son at any age.
Stroke - Mother, father, sister, brother, daughter or son at any age.
LIFESTYLE INFORMATION
Current Smoker - Do you currently smoke cigarettes?
Past Smoker - You are currently not smoking but did regularly smoke cigarettes
sometime in the past.
Exercise Frequency - On average, the number of times per week you do physical activity
for at least 20 minutes.
Exercise Intensity - When you are doing physical activity, how hard do you work?
MEDICATIONS (pills)
High Blood Pressure - Medicines for high blood pressure, also called hypertension,
are used to lower blood pressure to a safe level.
Lipid-Lowering - Medicines for high cholesterol, also called hypercholesterolemia or dyslipidemia,
which lower LDL cholesterol to safer levels or raise HDL cholesterol to safer levels.
Aspirin - Do you take an amount equal to at least one quarter (81mg) of an adult aspirin
daily?
FOR WOMEN ONLY
Currently Pregnant - The state of carrying a developing embryo or fetus within the female
body. During pregnancy, many changes occur in your clinical measurements; therefore it is not appropriate to use those clinical measurements to make
long term predictions of your chronic disease risk at this time. Reports cannot be generated.
Live Births - The number of children you have that were born alive.
Diagnosis of Gestational Diabetes - Develops or is discovered during pregnancy and
usually disappears when the pregnancy is over.
Years Since - Number of years since you were last diagnosed with gestational
diabetes.
Menopause - Have you gone through the change of life (stopped having periods, either naturally
or through surgery)?
HRT Use (after menopause only) - Do you use any form of hormone replacement that was prescribed
by your doctor?
FOR CURRENT SMOKERS ONLY
Have any of your blood relatives, living or dead, ever been told by their doctor that they have or had any of the following
conditions:
Lung Cancer - Mother or father at any age.
Have you ever been told by your doctor that you have or have had any of the following illnesses or conditions:
Lung Cancer - Cancer within the lungs.
COPD - COPD (Chronic Obstructive Pulmonary Disease) is a lung disease in which the lung is damaged, making it hard to
breathe. It is the result of asthma, chronic bronchitis, or emphysema.
Emphysema - A lung disease that causes the air sacs in the lungs to get bigger and causes
damage to them and makes it hard to breath.
Asthma (current diagnosis) and (past diagnosis) - Sometimes
begins with an allergic reaction making it hard to breath and produces wheezing, a sense of tightness in the chest, and coughing or gasping for
breath.
Cigarettes Smoked per Day - The average number of cigarettes you smoke in one day.
Years Smoked - The combined total number of years that you have smoked cigarettes.
ADDITIONAL DATA REQUIRED FOR BREAST OR PROSTATE AND COLORECTAL CANCER MODELS
PERSONAL INFORMATION
Have you ever been told by your doctor that you have or have had any of the following illnesses or conditions:
Colorectal Cancer - Either colon cancer or rectal cancer. Does not include colon polyps.
FAMILY HISTORY
Have any of your blood relatives, living or dead, ever been told by their doctor that they have or had any of the following
conditions:
Colorectal Cancer - Mother, father, sister, brother, daughter or son at any age.
LIFESTYLE INFORMATION
Red Meat - How many times per week do you eat
beef, pork, or lamb?
Alcohol - How many times each per week do you drink 12 ounces of beer, 5 ounces of wine
and/or 1 ounce of liquor?
FOR WOMEN ONLY
Have you ever been told by your doctor that you have or have had any of the following:
Breast Cancer - Does not include ductal carcinoma in situ
(DCIS).
Have any of your blood relatives, living or dead, ever been told by their doctor that they have or had any of the following:
Breast Cancer - mother or sister at any age.
PERSONAL INFORMATION
Age at Each Birth - List how old you were at the birth of each live baby you delivered.
Age at First Menstrual Period - How old were you when you started having your period?
Age at Menopause - How old were you were when you went through the change of life either
naturally or through surgery?
HRT (after menopause only) - Have you ever used any form of hormone replacement therapy?
FOR MEN ONLY
Have you ever been told by your doctor that you have or have had any of the following:
Prostate Cancer - Does not include an enlarged prostate or benign prostatic hyperplasia.
Have any of your blood relatives, living or dead, ever been told by their doctor that they have or had any of the following
conditions:
Prostate Cancer - Father or brother at any age.
BODY MEASUREMENTS
Height - The measurement from base to top or (of a standing person) from head to foot.
Weight - The heaviness of a person.
Waist Measurement – Waist is not the same as your pant size. To collect your waist
measurement, locate the top of the hip bone. Place a tape measure evenly around the bare abdomen at the level of this bone. Keep the measuring tape
snug but do not push tightly into the skin. Measure after breathing out normally; do not “suck in” your stomach.
CLINICAL INFORMATION AND LAB VALUES
Pulse Rate - Pulse rate is a result of the heart beating. As the heart beats and forces
blood through the body, throbbing sensation (the pulse) can be felt. It can be felt at any point where the artery comes close to the surface of the
skin, such as the wrist, neck, or upper arm. Counting the pulse rate is a simple way to estimate how fast the heart is beating. A pulse is usually
described in terms of its rate, which is the number of beats per minute (bpm).
Blood Pressure Systolic\Diastolic - Blood pressure is the pressure inside
the blood vessels as blood moves through the body. Blood pressure is measured in two numbers, systolic and diastolic. The systolic pressure (top number)
measures the force of the blood against your arteries when the heart contracts (beats) and the diastolic (lower number) pressure measures the force when
the heart relaxes between beats.
Fasting Status
Nothing by mouth except water and medications, usually for approximately 8 hours.
Blood Glucose
The main sugar in the blood and a major fuel supply for the body. It is essential to the functioning of all cells, especially
brain cells. Glucose is able to enter your body's cells only with the assistance of insulin. Insulin is a hormone that is created in the beta cells
of your pancreas and travels throughout your body serving as a kind of "door man." Without the "permission" of insulin, glucose cannot get into your
cells to do the critical work of fueling your body.
Total Cholesterol
Cholesterol is a fat-like substance that is mostly created in the liver from the fats, carbohydrates and proteins you eat. Despite
its bad reputation, cholesterol actually has a vital function; it is the "cement" that holds cell membranes together.
Triglycerides
A type of lipid in the blood. When you eat, your body digests the fats from your food and transports, by "carrier" proteins called
lipoproteins, the triglyceride through the blood to storage sites in various body tissues.
HDL and LDL CHOLESTEROL
Your HDL cholesterol, also known as your good cholesterol, helps remove LDL, or bad cholesterol, from the body and may offer
protection from diseases such as coronary heart disease, stroke, and diabetes.
LDL is often referred to as the bad cholesterol. This is the main source of cholesterol buildup and blockage in the arteries. The higher your
LDL level, the greater your risk for heart disease and stroke.
C-Reactive Protein
C-Reactive protein (CRP) is an acute phase reactant that is predictive of CHD at low but persistently elevated levels. The acute
phase response is a general inflammatory response to various insults such as infection, vaccinations, and minor surgery. Its mechanism and function are
not well understood.
Homocysteine
Homocysteine is an amino acid in the blood and is a byproduct of B vitamin deficiency . Too much homocysteine has been shown to
contribute to a higher risk of coronary heart disease, stroke and peripheral vascular disease. A direct causal link has not yet been established, but
evidence suggests that homocysteine may also have an effect on atherosclerosis by damaging the inner lining of arteries and promoting blood clots.
Lipoprotein (a)
Lipoprotein (a) (often called "lipoprotein little a") is a type of LDL particle. It has an extra protein called apolipoprotein (a).
This is really a family of proteins that vary slightly from person to person depending on genetic factors.
DIABETES COMPLICATIONS
Nephropathy
Microalbuminuria - Urinary albumin excretion rate of 20-200 mg/min (30-300 mg/24 h) or random urine sample of 30-300 mg/L.
Proteinuria - Two consecutive random urine samples with at least grade I (400 mg/L) protein.
ESRD (End Stage Renal Failure) - The levels of creatinine and urea, with an associated clinical course, that would be
considered by most clinicians to diagnose the patients with severe, progressive and irreversible renal failure. For example, two consecutive creatinine
values greater than or equal to 4.0 mg/dL (353.6 �mol/L); two consecutive urea values greater than or equal to 150 mg/dL (25.0 �mol/L) (in the absence
of creatinine values less than 4.0 mg/dL or when creatinine values were unavailable); persistent dialysis of any type; and renal transplant.
Neuropathy
Subclinical - Any neurologic examination that does not meet the definition of Clinical Neuropathy.
Polyneuropathy - Defined as an abnormal neurologic examination that is consistent with the presence of peripheral
sensorimotor neuropathy plus either abnormal nerve conduction in at least two peripheral nerves or unequivocally abnormal autonomic-nerve testing.
LEA - Lower extremity amputation.
Retinopathy - Fundus photographs graded using an abbreviation of the
Modified Airlie House classification from level 1 to level 6 as defined below.
Level 1: - No retinopathy.
Level 2: - Microaneurysms (one or more) only.
Level 3: - Microaneurysms and one or more of the following: retinal hemorrhages, but total hemorrhages and microaneurysms
(H/Ma) less than Standard Photo #2A; hard exudates (HE) less than Standard Photo #3; soft exudates (SE) questionably present; intraretinal microvascular
abnormalities (IRMA) questionably present; venous beading (VB) questionably present or venous focal narrowing or loops definitely present.
Level 4: - Microaneurysms and one or more of the following, but definition of Level 5 not met: H/Ma greater than or equal to
Standard Photo #2A; HE greater than or equal to Standard Photo #3; SE definitely present; IRMA definitely present; VB definitely present.
Level 5: - In fields 4 to 7 only, any three of the following: H/Ma greater than or equal to Standard Photo #2A in at least
one field; SE definitely present in 2 or more fields; IRMA definitely present in 2 or more fields; VB definitely present in 2 or more fields; or IRMA
present in 4 fields and greater than or equal to Standard Photo #8A in 2 or more fields.
Level 6: - New vessels and/or fibrous proliferations (disc or elsewhere) or scars of photocoagulation (either "scatter" or
confluent patches presumably directed at new vessels), or fundus obscured by vitreous hemorrhage.
Retinopathy stages below are based on the photo levels as defined above and other criteria. (The numbers indicate the level in both
eyes.)
NPDR (1) - Mild non-proliferative diabetic retinopathy (NPDR) - Photo grade level - 2/<2 to 2/2
NPDR (2) - Moderate NPDR - 3/<3 to 4/<4
NPDR (3) - Severe NPDR - 4/4 to 5/5
PDR - Proliferative diabetic retinopathy - 6/<6 or worse
Clinically Significant Macular Edema - Presence of any one of the following: thickening of the retina located 500/m or less
from the center of the macular; hard exudates with thickening of the adjacent retina 500/m or less from the center of the macular; or a zone of retinal
thickening one disc area or larger in size located one disc diameter or less from the center of the macula.
Blindness - Visual acuity <20/100 in better eye.
WELLNESS
The Wellness questions are about your feelings, attitudes, intentions, and beliefs about certain health issues. As such, it may be
hard to find the answer that exactly matches what you want to say. Recognizing that, simply find the answer that comes closest to what you want to say.
Also notice that each question has the option of giving no answer, if that is preferred.
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