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Category,Question,Base Question (Reference),Sub Question (Reference),SubQuestion,type,options
"Medical History, Family history",High blood pressure,,,,radio,"yes,no"
"Medical History, Family history",Heart attack,,,,radio,"yes,no"
"Medical History, Family history",High cholesterol,,,,radio,"yes,no"
"Medical History, Family history",Stroke/TIA,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Atrial Fib/Arrhythmia ,,,,radio,"yes,no"
"Medical History, Family history",PFO/ Hole in Heart,,,,radio,"yes,no"
"Medical History, Family history",Cancer,,,,radio,"yes,no"
"Medical History, Family history",Coagulopathy/Clotting disorder,,,,radio,"yes,no"
"Medical History, Family history",Diabetes ,,,,radio,"yes,no"
"Medical History, Family history",Kidney disease ,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Thyroid disease,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Do you drink alcohol?,,,,radio,"yes,no"
"Medical History, Family history",Current everyday,,,,radio,"yes,no"
"Medical History, Family history",Current someday,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
"Medical History, Family history",Beer/Wine/Liquor How many per week?,,,,text,
"Medical History, Family history",Do you use recreational Drugs?,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
"Medical History, Family history,Neurology",Have you ever used tobacco?,,,,radio,"Current everyday,Current someday,Former,Never,Unknown"
"Medical History, Family history",How many packs per day do you or did you smoke?,,,,radio,"< ½, ½ ,1,1 ½,2,2 1/2,3"
"Medical History, Family history",Smoking,,,,radio,"yes,no"
"Medical History, Family history",Angina,,,,radio,"yes,no"
"Medical History, Family history",Stent placement,,,,radio,"yes,no"
"Medical History, Family history",Bypass surgery,,,,radio,"yes,no"
"Medical History, Family history",Pacemaker implant,,,,radio,"yes,no"
"Medical History, Family history",Stroke,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Mini-stroke (TIA),,,,radio,"yes,no"
"Medical History, Family history,Neurology",Carotid surgery,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Aortic aneurysm,,,,radio,"yes,no"
"Medical History, Family history",Fast heart rate,,,,radio,"yes,no"
"Medical History, Family history",Sudden death,,,,radio,"yes,no"
"Medical History, Family history",Pulmonary embolism,,,,radio,"yes,no"
"Medical History, Family history",COPD (lung disease),,,,radio,"yes,no"
"Medical History, Family history,Neurology",Osteoporosis,,,,radio,"yes,no"
"Medical History, Family history",Mental illness,,,,radio,"yes,no"
"Medical History, Family history",Congestive heart failure,,,,radio,"yes,no"
"Medical History, Family history",Coronary artery disease,,,,radio,"yes,no"
"Medical History, Family history,Neurology,Urology",Depression,,,,radio,"yes,no"
"Medical History, Family history",Diverticulitis,,,,radio,"yes,no"
"Medical History, Family history",GERD (heartburn),,,,radio,"yes,no"
"Medical History, Family history,Neurology",Glaucoma,,,,radio,"yes,no"
"Medical History, Family history",Headaches,,,,radio,"yes,no"
"Medical History, Family history",Heart murmur,,,,radio,"yes,no"
"Medical History, Family history,Neurology,Urology",HIV/AIDS,,,,radio,"yes,no"
"Medical History, Family history",Hyperlipidemia (high cholesterol),,,,radio,"yes,no"
"Medical History, Family history",Hypertension (high blood pressure),,,,radio,"yes,no"
"Medical History, Family history",Hypothyroidism,,,,radio,"yes,no"
"Medical History, Family history",Irregular menses,,,,radio,"yes,no"
"Medical History, Family history",Kidney disease,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Liver disease,,,,radio,"yes,no"
"Medical History, Family history",Menorrhagia,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Myocardial infarction (heart attack),,,,radio,"yes,no"
"Medical History, Family history",Nerve/muscle disease,,,,radio,"yes,no"
"Medical History, Family history",Osteoporosis,,,,radio,"yes,no"
"Medical History, Family history,Urology",Seizures,,,,radio,"yes,no"
"Medical History, Family history",Sickle cell anemia,,,,radio,"yes,no"
"Medical History, Family history",Sleep apnea,,,,radio,"yes,no"
"Medical History, Family history",Substance abuse,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Tuberculosis,,,,radio,"yes,no"
"Medical History, Family history",Ulcers,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Appendectomy,,,,radio,"yes,no"
"Medical History, Family history",Bariatric surgery,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Brain surgery,,,,radio,"yes,no"
"Medical History, Family history",Breast surgery,,,,radio,"yes,no"
"Medical History, Family history",CABG (bypass),,,,radio,"yes,no"
"Medical History, Family history",Cesarean section,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Cholecystectomy (gall bladder removal),,,,radio,"yes,no"
"Medical History, Family history",Colon surgery,,,,radio,"yes,no"
"Medical History, Family history",Cosmetic surgery,,,,radio,"yes,no"
"Medical History, Family history",Eye surgery,,,,radio,"yes,no"
"Medical History, Family history",Fracture surgery,,,,radio,"yes,no"
"Medical History, Family history",Hernia repair,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Hysterectomy (ovaries removed),,,,radio,"yes,no"
"Medical History, Family history",Hysterectomy (ovaries remain),,,,radio,"yes,no"
"Medical History, Family history",Joint replacement,,,,radio,"yes,no"
"Medical History, Family history",Prostate surgery,,,,radio,"yes,no"
"Medical History, Family history",Small intestine surgery,,,,radio,"yes,no"
"Medical History, Family history",Spine surgery,,,,radio,"yes,no"
"Medical History, Family history",Tubal ligation (tubes tied),,,,radio,"yes,no"
"Medical History, Family history",Valve replacement,,,,radio,"yes,no"
"Medical History, Family history,Neurology",Peripheral Neuropathy,,,,checkbox,
"Medical History, Family history",Vasectomy,,,,radio,"yes,no"
"Medical History,Urology",Do you ever drink alcohol?,,,,radio,"Yes – if yes, complete all alcohol related questions,No – if no, skip to next section"
Medical History,,,,Please indicate the quantity per week of each,radio,"yes,no"
Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Glasses of wine,text,
Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Can/bottles of beer,text,
Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Shots of liquor,text,
Medical History,,Do you ever drink alcohol?,Please indicate the quantity per week of each,Drinks containing .5 oz of alcohol,text,
Medical History,Have people ever felt like you should cut down on drinking?,,,,radio,"yes,no"
Medical History,Have people annoyed you by criticizing your drinking?,,,,radio,"yes,no"
Medical History,Have you ever felt guilty about your drinking?,,,,radio,"yes,no"
Medical History,"Have you ever had an ""eye-opener"" (an alcoholic drink first thing in the morning) to help you feel better?",,,,radio,"yes,no"
Medical History,Drugs and tobacco,,,Do you use drugs?,radio,"yes,no"
Medical History,,,,"If you use drugs, how many times per week?",text,
Medical History,,,,What type(s) of drugs do you use? ,text,
Medical History,Check one of the following about smoking tobacco,,,,radio,"Never smoked,Exposed to second hand smoke,Former smoker,Smoke some days,Smoke everyday"
Medical History,"If you smoked or used to smoke, how many packs do or did you smoke per day?",,,,text,
Medical History,How many years did you smoke / have you smoked?,,,,text,
Medical History,"If you quit smoking, when did you quit?",,,,text,
"Medical History,Neurology",Check one of the following about smokeless tobacco,,,,radio,"Never usedm,Former user,Current user"
Medical History,"If you quit smokeless tobacco, when did you quit?",,,,text,
Medical History,Are you ready to quit smoking or using smokeless tobacco?,,,,text,
Medical History,Do you use e-cigarettes?,,,,radio,"No,Used in the past,Not presently,Occasionally,Daily"
"Medical History,Urology",Sexual activity,,,,,
Medical History,,Sexual activity,,Are you sexually active?,radio,"Yes,No,Not currently"
"Medical History,Urology",,Sexual activity,Are you sexually active?,"If yes, are your partner(s):",radio,"Male,Female,Both"
"Medical History,Urology",Type of birth control / protection (check all that you use):,,,,checkbox,"Not having sex (abstinence),Condom,Injection,IUD (intrauterine device),Oral contraceptives (Pill),Partner vasectomy,Patch,Post-Menopausal,Vasectomy,None,Other (specify):"
Medical History,Do you have a new sexual partner?,,,,text,
"Medical History,Oncology","On average, how many minutes do you engage in exercise at this level?",,,,radio,"0 min,10 min,20 min,30 min,40 min,50 min,60 min,70 min,80 min,90 min,100 min,110 min,120 min,130 min,140 min,150+ min"
"Medical History,Oncology","On average, how many days per week do you engage in moderate to strenuous exercise?",,,,radio,"1 day,2 days,3 days,4 days,5 days,6 days,7 days"
Medical History,,,,,radio,"yes,no"
"Medical History,Neurology",Tonsillectomy and Adenoidectomy,,,,radio,"yes,no"
Medical History,Marital status,,,,radio,"Divorced,Legally separated,Married,Significant other
Single,Widow,Unknown"
"Medical History, Family history",Leg-vascular surgery,,,,radio,"yes,no"
Medical History,Doctor Intake Request,,,,radio,"yes,no"
Medical History,,Doctor Intake Request,,What aspects of hormone replacement therapy (HRT) intrigue you?,text,
Medical History,,Doctor Intake Request,,Is your objective with the program to achieve weight loss?,radio,"yes,no"
Medical History,,Doctor Intake Request,,What is your assigned sex at birth?,,"male,female"
Medical History,,Doctor Intake Request,,"Have you undergone a comprehensive physical examination by a medical professional within the past three years, which included assessments of vital signs such as weight, blood pressure, and heart rate?",radio,"yes,no"
Medical History,,Doctor Intake Request,,"Did you experience any medical issues? If so, could you please elaborate?",radio,"yes,no"
Medical History,,Doctor Intake Request,,Have you ever received a diagnosis of prostate cancer?,radio,"yes,no"
Medical History,,Doctor Intake Request,,Have you been prescribed any hormone treatments currently or in the past?,radio,"Thyroid Medication,Testosterone Treatment,Estrogen Blocker,HGH,Ipamoreline,Colomipheine,HCG,Other,None"
Medical History,,Doctor Intake Request,,"Are you currently using or have you used any over-the-counter or prescription medications, excluding hormone treatments? (Please note that your responses will be cross-checked against prescription and insurance records. Failure to disclose current prescriptions and/or medical conditions may result in disapproval for your safety.)",radio,"yes,no"
Medical History,,Doctor Intake Request,,Do you have any allergies to medications?,radio,"yes,no"
Medical History,,Doctor Intake Request,,Do you intend to have children at some point in the future?,radio,"yes,no"
Medical History,,Doctor Intake Request,,Is your partner currently pregnant or breastfeeding?,radio,"yes,no,Not Applicable"
"Medical History,Neurology",,Doctor Intake Request,,Does your family have a history of any of the following disorders?,radio,"Drug Alcohol,Cancer,Heart Disease,Thyroid Disease,Low Testosterone,None"
Medical History,,Doctor Intake Request,,Are you currently experiencing any erectile dysfunction (ED) issues?,radio,"Never,Almost Never,Occasionally,Almost Always,Always"
Medical History,,Doctor Intake Request,,"Have you ever been diagnosed with thyroid disorders such as hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), Hashimoto's Disease, or Graves' Disease?",radio,"yes,no"
Medical History,How many years did you or have you smoked?,,,,radio,
"Medical History, Family history",Heart Disease,,,,text,
"Medical History, Family history,Neurology",Bleeding Disorder,,,,text,
"Medical History, Family history,Neurology",High Blood Pressure,,,,text,
"Medical History, Family history,Neurology",Blood Clots,,,,text,
"Medical History, Family history",High Cholesterol,,,,text,
"Medical History, Family history,Neurology",Cancer type and stroke,,,,text,
"Medical History, Family history,Neurology",Diabetes ,,,,text,
Medical History,Do you have any known Allergies to Medications?,,,,checkbox,
Medical History,,Do you have any known Allergies to Medications?,,,checkbox,
Medical History,,Do you have any known Allergies to Medications?,,Iodine,radio,"yes,no"
Medical History,,Do you have any known Allergies to Medications?,,Latex?,radio,"yes,no"
Medical History,,Do you have any known Allergies to Medications?,"Latex?,Iodine?",Reaction,text,
Medical History,,Do you have any known Allergies to Medications?,,Others?,radio,"yes,no"
Medical History,,,Others?,Please list Medication and Reaction,text,
Medical History,What is your current weight,,,,text,
Medical History,What is your current height,,,,radio,"yes,no"
Medical History,,What is your current height,,Feet,text,
Medical History,,What is your current height,,inches,text,
Medical History,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,,,checkbox,
Medical History,,,,Plavix/Clopidogrel:,radio,"yes,no"
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Plavix/Clopidogrel:,Dose/Frequency,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Plavix/Clopidogrel:,Reason,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Coumadin/Warfarin:,radio,"yes,no"
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Coumadin/Warfarin:,Dose/Frequency,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Coumadin/Warfarin:,Reason,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Aspirin,radio,"yes,no"
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Aspirin,Dose/Frequency,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,Aspirin,Reason,text,
Medical History,,ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS?,,Please list the Provider that is monitoring any of the above medications:,text,
Medical History,Review of Systems,,,,radio,"yes,no"
Medical History,,Review of Systems,,Constitutional,radio,"yes,no"
"Medical History,Oncology,Neurology",,Review of Systems,Constitutional,Fatigue/Drenching Night Sweats,checkbox,
"Medical History,Neurology",,Review of Systems,Constitutional,Fever/Chills,checkbox,
Medical History,,Review of Systems,Constitutional,General health excellent/Poor,checkbox,
"Medical History,Oncology",,Review of Systems,Constitutional,Unexplained weight loss/Gain,checkbox,
Medical History,,Review of Systems,,Respiratory,radio,"yes,no"
"Medical History,Neurology",,Review of Systems,Respiratory,Asthma/ Anesthetic problems,checkbox,
"Medical History,Neurology",,Review of Systems,Respiratory,COPD/Pneumonia/Emphysema,checkbox,
"Medical History,Oncology",,Review of Systems,Respiratory,Coughing/coughing up blood,checkbox,
"Medical History,Neurology",,Review of Systems,Respiratory,Hoarsness/Obstructive Sleep Apnea,checkbox,
Medical History,,Review of Systems,Respiratory,"Oxygen Dependent LPM ",checkbox,
"Medical History,Oncology",,Review of Systems,Respiratory,Shortness of Breath with Exertion,checkbox,
"Medical History,Neurology",,Review of Systems,Respiratory,Shortness of breath /Wheezing,checkbox,
Medical History,,Review of Systems,Respiratory,Tuberculosis or exposure,checkbox,
Medical History,,Review of Systems,,Neurological,radio,"yes,no"
"Medical History,Neurology",,Review of Systems,Neurological,Migraines/Headache/Vertigo,checkbox,
Medical History,,Review of Systems,Neurological,Temporary/Paralysis Arm/Leg/Face,checkbox,
"Medical History,Oncology,Neurology",,Review of Systems,Neurological,Tingling/Numbness,checkbox,
"Medical History,Oncology,Neurology",,Review of Systems,Neurological,Speech difficulties/Seizures,checkbox,
Medical History,,Review of Systems,,Eyes,radio,"yes,no"
"Medical History,Oncology",,Review of Systems,Eyes,Blurry vision/Double vision,checkbox,
Medical History,,Review of Systems,Eyes,Cataracts/ Macular degeneration,checkbox,
Medical History,,Review of Systems,Eyes,Glasses/Contacts/Blindness,checkbox,
Medical History,,Review of Systems,Eyes,Glaucoma/Retinopathy,checkbox,
Medical History,,Review of Systems,Eyes,Partial loss of vision/blind spots,checkbox,
"Medical History,Urology",,Review of Systems,,Gastrointestinal,radio,"yes,no"
"Medical History,Oncology",,Review of Systems,Gastrointestinal,Abdominal pain/Blood in stool,checkbox,
Medical History,,Review of Systems,Gastrointestinal,Black or Tarry stool,checkbox,
"Medical History,Oncology",,Review of Systems,Gastrointestinal,Bloating/Diarrhea/Constipation,checkbox,
"Medical History,Oncology",,Review of Systems,Gastrointestinal,Loss of appetite/Heartburn,checkbox,
"Medical History,Oncology",,Review of Systems,Gastrointestinal,Nausea/Vomiting,checkbox,
Medical History,,Review of Systems,Gastrointestinal,Ulcer disease/Pain after eating,checkbox,
Medical History,,Review of Systems,Gastrointestinal,Vomited blood,checkbox,
Medical History,,Review of Systems,,Endocrine,radio,"yes,no"
"Medical History,Urology",,Review of Systems,Endocrine,Cold/Heat intolerance,checkbox,
"Medical History,Urology",,Review of Systems,Endocrine,History of drug resistant infection,checkbox,
Medical History,,Review of Systems,,Ears/Nose/Mouth/Throat,radio,"yes,no"
Medical History,,Review of Systems,Ears/Nose/Mouth/Throat,Dentures/Difficulty swallowing,checkbox,
"Medical History,Oncology,Neurology",,Review of Systems,Ears/Nose/Mouth/Throat,Hearing Loss/ringing in ears,checkbox,
"Medical History,Neurology",,Review of Systems,Ears/Nose/Mouth/Throat,Prolonged Nose bleeds,checkbox,
Medical History,,Review of Systems,Ears/Nose/Mouth/Throat,Voice change,checkbox,
Medical History,,Review of Systems,,Psychiatric,radio,"yes,no"
"Medical History,Neurology",,Review of Systems,Psychiatric,Anxiety/Depression,checkbox,
Medical History,,Review of Systems,Psychiatric,Confusion/Memory loss,checkbox,
Medical History,,Review of Systems,Psychiatric,Difficulty sleeping,checkbox,
Medical History,,Review of Systems,,Cardiovascular,radio,"yes,no"
Medical History,,Review of Systems,Cardiovascular,Ankle Swelling /Varicosities,checkbox,
Medical History,,Review of Systems,Cardiovascular,Calf pain with/without exercise,checkbox,
"Medical History,Oncology",,Review of Systems,Cardiovascular,Chest pain with exertion/Exercise,checkbox,
Medical History,,Review of Systems,Cardiovascular,Chest pain/ Heart murmur,checkbox,
Medical History,,Review of Systems,Cardiovascular,Dyspnea on exertion/Syncope,checkbox,
Medical History,,Review of Systems,Cardiovascular,Irregular/Rapid heart rate,checkbox,
Medical History,,Review of Systems,Cardiovascular,Leg Pain/Cramping in legs at night,checkbox,
"Medical History,Oncology",,Review of Systems,,Genitourinary,checkbox,
Medical History,,Review of Systems,,Impotence,checkbox,
Medical History,,Review of Systems,Impotence,Incontinence /Difficulty Voiding,checkbox,
"Medical History,Neurology",,Review of Systems,Impotence,Kidney stones,checkbox,
Medical History,,Review of Systems,Impotence,Suprapubic/Indwelling Catheter,checkbox,
"Medical History,Neurology,Urology",,Review of Systems,Impotence,Urgency/Blood in Urine,checkbox,
Medical History,,Review of Systems,,Integumentary (Skin),radio,"yes,no"
Medical History,,Review of Systems,,New skin lesions/Skin Cancer,checkbox,
"Medical History,Oncology,Neurology",,Review of Systems,,Rash/Persistent itching,checkbox,
Medical History,,Review of Systems,,Unhealed/Delayed healing of sores,checkbox,
Medical History,,Review of Systems,,Heme/Lymphatic/Immune,radio,"yes,no"
Medical History,,Review of Systems,Heme/Lymphatic/Immune,Anemia/Low platelet count,checkbox,
"Medical History,Neurology",,Review of Systems,Heme/Lymphatic/Immune,Bleeding disorder/Easy bleeding,checkbox,
Medical History,,Review of Systems,Heme/Lymphatic/Immune,Easy bruising,checkbox,
Medical History,,Review of Systems,Heme/Lymphatic/Immune,Lymphoma/Leukemia,checkbox,
Medical History,,Review of Systems,Heme/Lymphatic/Immune,Frequent illnesses,checkbox,
ALLERGY/ASTHMA ,COUGH OR WHEEZE SYMPTOMS,,,,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,DAYTIME SYMPTOMS,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,less than twice weekly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,more than twice weekly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DAYTIME SYMPTOMS,daily,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,"DAYTIME SYMPTOMS,NIGHT SYMPTOMS",continuous,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,NIGHT SYMPTOMS,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,less than twice monthly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,more than twice monthly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,NIGHT SYMPTOMS,nightly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,DURING OR AFTER EXERCISE,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,exercise symptoms may occur,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,less than once weekly,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,frequent exercise symptoms,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,DURING OR AFTER EXERCISE,significant limitation activity,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,,EXTRA ALBUTEROL USE,radio,"yes,no"
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,occasional use,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,periods of daily use,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,daily use,checkbox,
ALLERGY/ASTHMA ,,COUGH OR WHEEZE SYMPTOMS,EXTRA ALBUTEROL USE,frequent daily need,checkbox,
ALLERGY/ASTHMA ,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,,,radio,"yes,no"
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,TRIGGERS OF COUGH OR WHEEZE:,radio,"yes,no"
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,colds/infection,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,morning,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,night,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,exercise,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,cold air,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,outdoors,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,paint fumes,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,changes in humidity,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,school/work environment,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,"allergies ",checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,stress,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,second hand smoke,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,tobacco use,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,perfume/aerosol sprays,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,"mile run time ",checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),TRIGGERS OF COUGH OR WHEEZE:,pneumonia/bronchitis,checkbox,
ALLERGY/ASTHMA ,,Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),,MONTHS OF SYMPTOMS:,radio,"yes,no"
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",January,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 11 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",February,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 12 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",March,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 13 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",April,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 14 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",May,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 15 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",June,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 16 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",July,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 17 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",August,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 18 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",September,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 19 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",October,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 20 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",November,checkbox,
ALLERGY/ASTHMA ,,"Please rank how severe symptoms are from 1-10 (1 the least and 21 the most),ALLERGY - LIKE SYMPTOMS","MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS",December,checkbox,
ALLERGY/ASTHMA ,ALLERGY - LIKE SYMPTOMS,,,,radio,"yes,no"
ALLERGY/ASTHMA ,,,,UPPER RESPIRATORY SYMPTOMS,radio,"yes,no"
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sneezing,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sniffing/drippy nose,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,itchy eyes/nose,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,dark circles under eyes,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,sinus infection,checkbox,
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,mouth breathing/snoring,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,congestion,checkbox,
"ALLERGY/ASTHMA, Oncology, Neurology",,ALLERGY - LIKE SYMPTOMS,UPPER RESPIRATORY SYMPTOMS,headaches,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,,OTHER,text,
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,OTHER,eczema,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,hives,checkbox,
"ALLERGY/ASTHMA ,Neurology",,ALLERGY - LIKE SYMPTOMS,OTHER,dry skin,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,itchy skin,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,ear infection,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,nausea,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,dry cough,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,OTHER,throat clearing,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,,EXPOSURES,radio,"yes,no"
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,Smoke,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,fireplace/woodstove,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,animals,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,"feather (pillows, stuffed animals)",checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,carpeting,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,bedroom carpeting,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,forced air heat,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,mold in lower level,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,humidifier/vaporizer,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,bedroom in lower level,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,rural,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,city,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,EXPOSURES,suburbs,checkbox,
"ALLERGY/ASTHMA , Urology",,ALLERGY - LIKE SYMPTOMS,,ENVIRONMENTAL CONTROLS,radio,"yes,no"
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,air conditioning,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,HEPA filter,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,dehumidifier,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,wood floors,checkbox,
ALLERGY/ASTHMA ,,ALLERGY - LIKE SYMPTOMS,ENVIRONMENTAL CONTROLS,mattress & pillow covers,checkbox,
ALLERGY/ASTHMA ,TESTING/EVALUATION/EDUCATION:,TESTING/EVALUATION/EDUCATION:,,Has the patient ever had a breathing/lung function test?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,Has the patient ever had a breathing/lung function test?,"If yes, when?",text,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have an action plan at school/daycare?,radio,"yes,no"
ALLERGY/ASTHMA ,Please check those items which trigger your child’s allergy or asthma symptoms,,,,checkbox,"Dust,Cold Air,Exercise,Viral Infection,Ear or Sinus Infections,Weather Changes,Pollens,Cigarette Smoke,Strong odors,Cats,Dogs"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,, Has the patient ever had allergy testing?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Has the patient had their flu vaccine this year?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Has the patient ever had flu vaccine?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have an action plan at home? ,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Do you have any questions about your action plan?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Have you received asthma information?,radio,"yes,no"
ALLERGY/ASTHMA ,,TESTING/EVALUATION/EDUCATION:,,Would you like more information? ,radio,"classes,reading material,websites"
Cardiology,Personal History,,,,radio,"yes,no"
"Cardiology,Oncology,Neurology",,Personal History,,Dizziness or fainting,radio,"Within last 30 days,In the past"
"Cardiology,Neurology",,Personal History,,Falls that caused an injury,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Stroke,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Shortness of breath when walking 1 to 2 blocks,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Shortness of breath when climbing 1 flight of stairs,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Shortness of breath when lying down,radio,"Within last 30 days,In the past"
"Cardiology,Neurology,Urology",,Personal History,,Lower leg cramps while walking,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Bleeding problems or low iron (also called anemia),radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Blood clot in leg (also called phlebitis),radio,"Within last 30 days,In the past"
"Cardiology,Neurology",,Personal History,,High cholesterol,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Diabetes,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,High blood pressure,radio,"Within last 30 days,In the past"
"Cardiology,Neurology",,Personal History,,Heart murmur or abnormal heart valve,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Uncomfortable feeling in the chest,radio,"Within last 30 days,In the past"
"Cardiology,Neurology",,Personal History,,Chest pain with activity (also called angina),radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Heart attack (also called myocardial infarction),radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,Swollen legs,radio,"Within last 30 days,In the past"
Cardiology,,Personal History,,ankles or feet,radio,"Within last 30 days,In the past"
"Cardiology,Oncology",,Personal History,,Irregular heartbeat,radio,"Within last 30 days,In the past"
Cardiology,Have you had any of the following tests or procedures,,,,radio,"yes,no"
Cardiology,,Have you had any of the following tests or procedures,,Stress test or treadmill test:,radio,
Cardiology,,Have you had any of the following tests or procedures,,Cardiac catheterization or angiogram:,radio,
Cardiology,,Have you had any of the following tests or procedures,,Angioplasty or stent,radio,
"Cardiology,Neurology",,Have you had any of the following tests or procedures,,"Heart surgery If so, what kind?",radio,"yes,no"
Cardiology,,Have you had any of the following tests or procedures,"Heart surgery If so, what kind?",please explain,text,
Cardiology,"Do you follow a special meal plan or diet (such as Atkins®, Weight Watchers®, vegetarian, low fat, or diabetic)?",,,,radio,"yes,no"
Cardiology,,"Do you follow a special meal plan or diet (such as Atkins®, Weight Watchers®, vegetarian, low fat, or diabetic)?",,"If YES, which meal plan or diet do you follow?",text,
Cardiology,Do you exercise regularly?,,,,radio,"yes,no"
Cardiology,,Do you exercise regularly?,,"If YES, how many days a week?",text,
"Oncology,Neruology",Fever over 100 degrees F,,,,checkbox,
"Oncology,Neurology",Bone pain,,,,checkbox,
"Oncology,Neruology",Joint pain or stiffness,,,,checkbox,
Oncology,Lumps under the skin,,,,checkbox,
Oncology,New spots,,,,checkbox,
Oncology,Sores that won’t heal,,,,checkbox,
Oncology,Yellowing of eyes or skin (jaundice),,,,checkbox,
Oncology,Serious cough that brings up a lot of mucus or phlegm,,,,checkbox,
"Oncology,Neruology","Weakness in hand, arm, or leg",,,,checkbox,
Oncology,Problems with balance,,,,checkbox,
Oncology,Dry mouth,,,,checkbox,
Oncology,Problems chewing,,,,checkbox,
Oncology,Problems swallowing,,,,checkbox,
Oncology,Problems remembering things,,,,checkbox,
Oncology,Hard time finding the right word,,,,checkbox,
Oncology,Hard time concentrating,,,,checkbox,
"Oncology,Neruology",Double vision,,,,checkbox,
Oncology,Sudden need to urinate,,,,checkbox,
"Oncology,urology",Leaking urine,,,,checkbox,
Oncology,Are you having pain now?,,,,radio,"yes,no"
Oncology,,Are you having pain now?,,"If YES, where is your pain?",text,
Oncology,,,,How often are you in pain?,text,
Oncology,,,,When did your pain start?,text,
Oncology,"How would you describe your pain on a scale from 0 to 10, with 0 being no pain and 10 being worst pain ever?",,,,radio,"0 ,1, 2, 3, 4, 5, 6, 7, 8, 9,10"
Oncology,Are you controlling your pain with medicine?,,,,radio,"yes,no"
Oncology,,Are you controlling your pain with medicine?,,"If YES, what pain medicine do you take?",text,
Oncology,,,,How often do you take this pain medicine?,text,
Oncology,"Do you live in an Assisted Living Facility, Adult Family Home, Nursing Home?",,,,radio,"yes,no"
Oncology,May we give information about your health to another person?,,,,radio,"yes,no"
Oncology,,May we give information about your health to another person?,,Name of person,text,
Oncology,,May we give information about your health to another person?,,Relationship to you,text,
Oncology,Does anyone from Home Health or Hospice visit you at home?,,,,radio,"yes,no"
Oncology,Have you been able to continue most of your normal activities?,,,,radio,"yes,no"
Neurology, Atrial fibrillation,,,,checkbox,
Neurology,Bowel Problems,,,,checkbox,
Neurology,Crohn’s Disease,,,,checkbox,
Neurology,Loss of consciousness,,,,text,
Neurology,Parkinson’s Disease,,,,checkbox,
Neurology,Fibromyalgia,,,,checkbox,
Neurology,Stomach Ulcers,,,,text,
Neurology,Neck Surgery,,,,checkbox,
Neurology,Back Surgery,,,,checkbox,
Neurology,Aneurysm Surgery,,,,checkbox,
Neurology,Abdominal Surgery,,,,checkbox,
Neurology,Bowel Surgery,,,,checkbox,
Neurology,Bypass in the legs,,,,checkbox,
Neurology,Gallbladder Surgery,,,,checkbox,
Neurology,Gastric bypass surgery,,,,checkbox,
Neurology,Gynecologic surgery,,,,checkbox,
Neurology,Implants Type,,,,text,
Neurology,Intrathecal Pump,,,,checkbox,
Neurology,Pacemaker Surgery,,,,checkbox,
Neurology,Stimulator,,,,checkbox,
Neurology,Use caffeine,,,,checkbox,
Neurology,Street Drug,,,,text,
Neurology,Dementia,,,,radio,"yes,no"
Neurology,Epilepsy,,,,radio,"yes,no"
Neurology,Migraine Headaches,,,,radio,"yes,no"
Neurology,Polyneuropathy,,,,radio,"yes,no"
Neurology,Tremor,,,,radio,"yes,no"
Neurology,Poor memory,,,,checkbox,
Neurology,Difficulty finding words,,,,checkbox,
Neurology,Frequent sore throat,,,,checkbox,
Neurology,Hoarseness,,,,checkbox,
Neurology,Discharge from nose,,,,checkbox,
Neurology,Repeated sinus infections,,,,checkbox,
Neurology,Palpitations,,,,checkbox,
Neurology,Irregular heart beat,,,,checkbox,
Neurology,Cold hands,,,,checkbox,
Neurology,Cold feet,,,,checkbox,
Neurology,Chronic cough,,,,checkbox,
Neurology,Muscle loss,,,,checkbox,
"Neurology,urology",Excessive thirst,,,,checkbox,
Neurology,Farsighted,,,,checkbox,
Neurology,Nearsighted,,,,checkbox,
Neurology,Changes in hair,,,,checkbox,
Neurology,Changes in nails,,,,checkbox,
Neurology,Changes in skin color,,,,checkbox,
Neurology,Dry skin,,,,checkbox,
Dermatology,"Over the last week, how itchy, sore,painful or stinging has your skin been?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how embarrassed or self conscious have you been because of your skin?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin influenced the clothes you wear?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin affected any social or leisure activities?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin made it difficult for you to do any sport?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, has your skin prevented you from working or studying?",,,,radio,"yes,no"
Dermatology,"If ""No"", over the last week how much has your skin been a problem at work or studying?",,,,radio,"A lot,A little,Not at all"
Dermatology,"Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much has your skin caused any sexual difficulties?",,,,radio,"Very much,A lot,A little, Not at all"
Dermatology,"Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time?",,,,radio,"Very much,A lot,A little, Not at all"
Urology,Are you interested in smoking cessation counseling?,,,,radio,"yes,no"
Urology,Living Will or Power of Attorney,,,,checkbox,
Urology,Living Will or Power of Attorney,,,,checkbox,
Urology,Surrogate Designation (name/relation),,,,text,
"Medical History, Family history,Urology",Anesthesia Problems,,,,checkbox,
"Medical History, Family history,Urology",Urolithiasis (Urinary Stones),,,,checkbox,
Urology,extreme and insatiable hunger,,,,checkbox,
Urology,genital pain,,,,checkbox,
Urology,the sensation of pain and/or burning,,,,checkbox,
Urology,Urinary incontinence problem,,,,checkbox,
Urology,Genital Sore,,,,checkbox,
1 Category Question Base Question (Reference) Sub Question (Reference) SubQuestion type options
2 Medical History, Family history High blood pressure radio yes,no
3 Medical History, Family history Heart attack radio yes,no
4 Medical History, Family history High cholesterol radio yes,no
5 Medical History, Family history Stroke/TIA radio yes,no
6 Medical History, Family history,Neurology Atrial Fib/Arrhythmia radio yes,no
7 Medical History, Family history PFO/ Hole in Heart radio yes,no
8 Medical History, Family history Cancer radio yes,no
9 Medical History, Family history Coagulopathy/Clotting disorder radio yes,no
10 Medical History, Family history Diabetes radio yes,no
11 Medical History, Family history Kidney disease radio yes,no
12 Medical History, Family history,Neurology Thyroid disease radio yes,no
13 Medical History, Family history,Neurology Do you drink alcohol? radio yes,no
14 Medical History, Family history Current everyday radio yes,no
15 Medical History, Family history Current someday radio Current everyday,Current someday,Former,Never,Unknown
16 Medical History, Family history Beer/Wine/Liquor How many per week? text
17 Medical History, Family history Do you use recreational Drugs? radio Current everyday,Current someday,Former,Never,Unknown
18 Medical History, Family history,Neurology Have you ever used tobacco? radio Current everyday,Current someday,Former,Never,Unknown
19 Medical History, Family history How many packs per day do you or did you smoke? radio < ½, ½ ,1,1 ½,2,2 1/2,3
20 Medical History, Family history Smoking radio yes,no
21 Medical History, Family history Angina radio yes,no
22 Medical History, Family history Stent placement radio yes,no
23 Medical History, Family history Bypass surgery radio yes,no
24 Medical History, Family history Pacemaker implant radio yes,no
25 Medical History, Family history Stroke radio yes,no
26 Medical History, Family history,Neurology Mini-stroke (TIA) radio yes,no
27 Medical History, Family history,Neurology Carotid surgery radio yes,no
28 Medical History, Family history,Neurology Aortic aneurysm radio yes,no
29 Medical History, Family history Fast heart rate radio yes,no
30 Medical History, Family history Sudden death radio yes,no
31 Medical History, Family history Pulmonary embolism radio yes,no
32 Medical History, Family history COPD (lung disease) radio yes,no
33 Medical History, Family history,Neurology Osteoporosis radio yes,no
34 Medical History, Family history Mental illness radio yes,no
35 Medical History, Family history Congestive heart failure radio yes,no
36 Medical History, Family history Coronary artery disease radio yes,no
37 Medical History, Family history,Neurology,Urology Depression radio yes,no
38 Medical History, Family history Diverticulitis radio yes,no
39 Medical History, Family history GERD (heartburn) radio yes,no
40 Medical History, Family history,Neurology Glaucoma radio yes,no
41 Medical History, Family history Headaches radio yes,no
42 Medical History, Family history Heart murmur radio yes,no
43 Medical History, Family history,Neurology,Urology HIV/AIDS radio yes,no
44 Medical History, Family history Hyperlipidemia (high cholesterol) radio yes,no
45 Medical History, Family history Hypertension (high blood pressure) radio yes,no
46 Medical History, Family history Hypothyroidism radio yes,no
47 Medical History, Family history Irregular menses radio yes,no
48 Medical History, Family history Kidney disease radio yes,no
49 Medical History, Family history,Neurology Liver disease radio yes,no
50 Medical History, Family history Menorrhagia radio yes,no
51 Medical History, Family history,Neurology Myocardial infarction (heart attack) radio yes,no
52 Medical History, Family history Nerve/muscle disease radio yes,no
53 Medical History, Family history Osteoporosis radio yes,no
54 Medical History, Family history,Urology Seizures radio yes,no
55 Medical History, Family history Sickle cell anemia radio yes,no
56 Medical History, Family history Sleep apnea radio yes,no
57 Medical History, Family history Substance abuse radio yes,no
58 Medical History, Family history,Neurology Tuberculosis radio yes,no
59 Medical History, Family history Ulcers radio yes,no
60 Medical History, Family history,Neurology Appendectomy radio yes,no
61 Medical History, Family history Bariatric surgery radio yes,no
62 Medical History, Family history,Neurology Brain surgery radio yes,no
63 Medical History, Family history Breast surgery radio yes,no
64 Medical History, Family history CABG (bypass) radio yes,no
65 Medical History, Family history Cesarean section radio yes,no
66 Medical History, Family history,Neurology Cholecystectomy (gall bladder removal) radio yes,no
67 Medical History, Family history Colon surgery radio yes,no
68 Medical History, Family history Cosmetic surgery radio yes,no
69 Medical History, Family history Eye surgery radio yes,no
70 Medical History, Family history Fracture surgery radio yes,no
71 Medical History, Family history Hernia repair radio yes,no
72 Medical History, Family history,Neurology Hysterectomy (ovaries removed) radio yes,no
73 Medical History, Family history Hysterectomy (ovaries remain) radio yes,no
74 Medical History, Family history Joint replacement radio yes,no
75 Medical History, Family history Prostate surgery radio yes,no
76 Medical History, Family history Small intestine surgery radio yes,no
77 Medical History, Family history Spine surgery radio yes,no
78 Medical History, Family history Tubal ligation (tubes tied) radio yes,no
79 Medical History, Family history Valve replacement radio yes,no
80 Medical History, Family history,Neurology Peripheral Neuropathy checkbox
81 Medical History, Family history Vasectomy radio yes,no
82 Medical History,Urology Do you ever drink alcohol? radio Yes – if yes, complete all alcohol related questions,No – if no, skip to next section
83 Medical History Please indicate the quantity per week of each radio yes,no
84 Medical History Do you ever drink alcohol? Please indicate the quantity per week of each Glasses of wine text
85 Medical History Do you ever drink alcohol? Please indicate the quantity per week of each Can/bottles of beer text
86 Medical History Do you ever drink alcohol? Please indicate the quantity per week of each Shots of liquor text
87 Medical History Do you ever drink alcohol? Please indicate the quantity per week of each Drinks containing .5 oz of alcohol text
88 Medical History Have people ever felt like you should cut down on drinking? radio yes,no
89 Medical History Have people annoyed you by criticizing your drinking? radio yes,no
90 Medical History Have you ever felt guilty about your drinking? radio yes,no
91 Medical History Have you ever had an "eye-opener" (an alcoholic drink first thing in the morning) to help you feel better? radio yes,no
92 Medical History Drugs and tobacco Do you use drugs? radio yes,no
93 Medical History If you use drugs, how many times per week? text
94 Medical History What type(s) of drugs do you use? text
95 Medical History Check one of the following about smoking tobacco radio Never smoked,Exposed to second hand smoke,Former smoker,Smoke some days,Smoke everyday
96 Medical History If you smoked or used to smoke, how many packs do or did you smoke per day? text
97 Medical History How many years did you smoke / have you smoked? text
98 Medical History If you quit smoking, when did you quit? text
99 Medical History,Neurology Check one of the following about smokeless tobacco radio Never usedm,Former user,Current user
100 Medical History If you quit smokeless tobacco, when did you quit? text
101 Medical History Are you ready to quit smoking or using smokeless tobacco? text
102 Medical History Do you use e-cigarettes? radio No,Used in the past,Not presently,Occasionally,Daily
103 Medical History,Urology Sexual activity
104 Medical History Sexual activity Are you sexually active? radio Yes,No,Not currently
105 Medical History,Urology Sexual activity Are you sexually active? If yes, are your partner(s): radio Male,Female,Both
106 Medical History,Urology Type of birth control / protection (check all that you use): checkbox Not having sex (abstinence),Condom,Injection,IUD (intrauterine device),Oral contraceptives (Pill),Partner vasectomy,Patch,Post-Menopausal,Vasectomy,None,Other (specify):
107 Medical History Do you have a new sexual partner? text
108 Medical History,Oncology On average, how many minutes do you engage in exercise at this level? radio 0 min,10 min,20 min,30 min,40 min,50 min,60 min,70 min,80 min,90 min,100 min,110 min,120 min,130 min,140 min,150+ min
109 Medical History,Oncology On average, how many days per week do you engage in moderate to strenuous exercise? radio 1 day,2 days,3 days,4 days,5 days,6 days,7 days
110 Medical History radio yes,no
111 Medical History,Neurology Tonsillectomy and Adenoidectomy radio yes,no
112 Medical History Marital status radio Divorced,Legally separated,Married,Significant other Single,Widow,Unknown
113 Medical History, Family history Leg-vascular surgery radio yes,no
114 Medical History Doctor Intake Request radio yes,no
115 Medical History Doctor Intake Request What aspects of hormone replacement therapy (HRT) intrigue you? text
116 Medical History Doctor Intake Request Is your objective with the program to achieve weight loss? radio yes,no
117 Medical History Doctor Intake Request What is your assigned sex at birth? male,female
118 Medical History Doctor Intake Request Have you undergone a comprehensive physical examination by a medical professional within the past three years, which included assessments of vital signs such as weight, blood pressure, and heart rate? radio yes,no
119 Medical History Doctor Intake Request Did you experience any medical issues? If so, could you please elaborate? radio yes,no
120 Medical History Doctor Intake Request Have you ever received a diagnosis of prostate cancer? radio yes,no
121 Medical History Doctor Intake Request Have you been prescribed any hormone treatments currently or in the past? radio Thyroid Medication,Testosterone Treatment,Estrogen Blocker,HGH,Ipamoreline,Colomipheine,HCG,Other,None
122 Medical History Doctor Intake Request Are you currently using or have you used any over-the-counter or prescription medications, excluding hormone treatments? (Please note that your responses will be cross-checked against prescription and insurance records. Failure to disclose current prescriptions and/or medical conditions may result in disapproval for your safety.) radio yes,no
123 Medical History Doctor Intake Request Do you have any allergies to medications? radio yes,no
124 Medical History Doctor Intake Request Do you intend to have children at some point in the future? radio yes,no
125 Medical History Doctor Intake Request Is your partner currently pregnant or breastfeeding? radio yes,no,Not Applicable
126 Medical History,Neurology Doctor Intake Request Does your family have a history of any of the following disorders? radio Drug Alcohol,Cancer,Heart Disease,Thyroid Disease,Low Testosterone,None
127 Medical History Doctor Intake Request Are you currently experiencing any erectile dysfunction (ED) issues? radio Never,Almost Never,Occasionally,Almost Always,Always
128 Medical History Doctor Intake Request Have you ever been diagnosed with thyroid disorders such as hypothyroidism (underactive thyroid), hyperthyroidism (overactive thyroid), Hashimoto's Disease, or Graves' Disease? radio yes,no
129 Medical History How many years did you or have you smoked? radio
130 Medical History, Family history Heart Disease text
131 Medical History, Family history,Neurology Bleeding Disorder text
132 Medical History, Family history,Neurology High Blood Pressure text
133 Medical History, Family history,Neurology Blood Clots text
134 Medical History, Family history High Cholesterol text
135 Medical History, Family history,Neurology Cancer type and stroke text
136 Medical History, Family history,Neurology Diabetes text
137 Medical History Do you have any known Allergies to Medications? checkbox
138 Medical History Do you have any known Allergies to Medications? checkbox
139 Medical History Do you have any known Allergies to Medications? Iodine radio yes,no
140 Medical History Do you have any known Allergies to Medications? Latex? radio yes,no
141 Medical History Do you have any known Allergies to Medications? Latex?,Iodine? Reaction text
142 Medical History Do you have any known Allergies to Medications? Others? radio yes,no
143 Medical History Others? Please list Medication and Reaction text
144 Medical History What is your current weight text
145 Medical History What is your current height radio yes,no
146 Medical History What is your current height Feet text
147 Medical History What is your current height inches text
148 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? checkbox
149 Medical History Plavix/Clopidogrel: radio yes,no
150 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Plavix/Clopidogrel: Dose/Frequency text
151 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Plavix/Clopidogrel: Reason text
152 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Coumadin/Warfarin: radio yes,no
153 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Coumadin/Warfarin: Dose/Frequency text
154 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Coumadin/Warfarin: Reason text
155 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Aspirin radio yes,no
156 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Aspirin Dose/Frequency text
157 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Aspirin Reason text
158 Medical History ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? Please list the Provider that is monitoring any of the above medications: text
159 Medical History Review of Systems radio yes,no
160 Medical History Review of Systems Constitutional radio yes,no
161 Medical History,Oncology,Neurology Review of Systems Constitutional Fatigue/Drenching Night Sweats checkbox
162 Medical History,Neurology Review of Systems Constitutional Fever/Chills checkbox
163 Medical History Review of Systems Constitutional General health excellent/Poor checkbox
164 Medical History,Oncology Review of Systems Constitutional Unexplained weight loss/Gain checkbox
165 Medical History Review of Systems Respiratory radio yes,no
166 Medical History,Neurology Review of Systems Respiratory Asthma/ Anesthetic problems checkbox
167 Medical History,Neurology Review of Systems Respiratory COPD/Pneumonia/Emphysema checkbox
168 Medical History,Oncology Review of Systems Respiratory Coughing/coughing up blood checkbox
169 Medical History,Neurology Review of Systems Respiratory Hoarsness/Obstructive Sleep Apnea checkbox
170 Medical History Review of Systems Respiratory Oxygen Dependent LPM checkbox
171 Medical History,Oncology Review of Systems Respiratory Shortness of Breath with Exertion checkbox
172 Medical History,Neurology Review of Systems Respiratory Shortness of breath /Wheezing checkbox
173 Medical History Review of Systems Respiratory Tuberculosis or exposure checkbox
174 Medical History Review of Systems Neurological radio yes,no
175 Medical History,Neurology Review of Systems Neurological Migraines/Headache/Vertigo checkbox
176 Medical History Review of Systems Neurological Temporary/Paralysis Arm/Leg/Face checkbox
177 Medical History,Oncology,Neurology Review of Systems Neurological Tingling/Numbness checkbox
178 Medical History,Oncology,Neurology Review of Systems Neurological Speech difficulties/Seizures checkbox
179 Medical History Review of Systems Eyes radio yes,no
180 Medical History,Oncology Review of Systems Eyes Blurry vision/Double vision checkbox
181 Medical History Review of Systems Eyes Cataracts/ Macular degeneration checkbox
182 Medical History Review of Systems Eyes Glasses/Contacts/Blindness checkbox
183 Medical History Review of Systems Eyes Glaucoma/Retinopathy checkbox
184 Medical History Review of Systems Eyes Partial loss of vision/blind spots checkbox
185 Medical History,Urology Review of Systems Gastrointestinal radio yes,no
186 Medical History,Oncology Review of Systems Gastrointestinal Abdominal pain/Blood in stool checkbox
187 Medical History Review of Systems Gastrointestinal Black or Tarry stool checkbox
188 Medical History,Oncology Review of Systems Gastrointestinal Bloating/Diarrhea/Constipation checkbox
189 Medical History,Oncology Review of Systems Gastrointestinal Loss of appetite/Heartburn checkbox
190 Medical History,Oncology Review of Systems Gastrointestinal Nausea/Vomiting checkbox
191 Medical History Review of Systems Gastrointestinal Ulcer disease/Pain after eating checkbox
192 Medical History Review of Systems Gastrointestinal Vomited blood checkbox
193 Medical History Review of Systems Endocrine radio yes,no
194 Medical History,Urology Review of Systems Endocrine Cold/Heat intolerance checkbox
195 Medical History,Urology Review of Systems Endocrine History of drug resistant infection checkbox
196 Medical History Review of Systems Ears/Nose/Mouth/Throat radio yes,no
197 Medical History Review of Systems Ears/Nose/Mouth/Throat Dentures/Difficulty swallowing checkbox
198 Medical History,Oncology,Neurology Review of Systems Ears/Nose/Mouth/Throat Hearing Loss/ringing in ears checkbox
199 Medical History,Neurology Review of Systems Ears/Nose/Mouth/Throat Prolonged Nose bleeds checkbox
200 Medical History Review of Systems Ears/Nose/Mouth/Throat Voice change checkbox
201 Medical History Review of Systems Psychiatric radio yes,no
202 Medical History,Neurology Review of Systems Psychiatric Anxiety/Depression checkbox
203 Medical History Review of Systems Psychiatric Confusion/Memory loss checkbox
204 Medical History Review of Systems Psychiatric Difficulty sleeping checkbox
205 Medical History Review of Systems Cardiovascular radio yes,no
206 Medical History Review of Systems Cardiovascular Ankle Swelling /Varicosities checkbox
207 Medical History Review of Systems Cardiovascular Calf pain with/without exercise checkbox
208 Medical History,Oncology Review of Systems Cardiovascular Chest pain with exertion/Exercise checkbox
209 Medical History Review of Systems Cardiovascular Chest pain/ Heart murmur checkbox
210 Medical History Review of Systems Cardiovascular Dyspnea on exertion/Syncope checkbox
211 Medical History Review of Systems Cardiovascular Irregular/Rapid heart rate checkbox
212 Medical History Review of Systems Cardiovascular Leg Pain/Cramping in legs at night checkbox
213 Medical History,Oncology Review of Systems Genitourinary checkbox
214 Medical History Review of Systems Impotence checkbox
215 Medical History Review of Systems Impotence Incontinence /Difficulty Voiding checkbox
216 Medical History,Neurology Review of Systems Impotence Kidney stones checkbox
217 Medical History Review of Systems Impotence Suprapubic/Indwelling Catheter checkbox
218 Medical History,Neurology,Urology Review of Systems Impotence Urgency/Blood in Urine checkbox
219 Medical History Review of Systems Integumentary (Skin) radio yes,no
220 Medical History Review of Systems New skin lesions/Skin Cancer checkbox
221 Medical History,Oncology,Neurology Review of Systems Rash/Persistent itching checkbox
222 Medical History Review of Systems Unhealed/Delayed healing of sores checkbox
223 Medical History Review of Systems Heme/Lymphatic/Immune radio yes,no
224 Medical History Review of Systems Heme/Lymphatic/Immune Anemia/Low platelet count checkbox
225 Medical History,Neurology Review of Systems Heme/Lymphatic/Immune Bleeding disorder/Easy bleeding checkbox
226 Medical History Review of Systems Heme/Lymphatic/Immune Easy bruising checkbox
227 Medical History Review of Systems Heme/Lymphatic/Immune Lymphoma/Leukemia checkbox
228 Medical History Review of Systems Heme/Lymphatic/Immune Frequent illnesses checkbox
229 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS radio yes,no
230 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DAYTIME SYMPTOMS radio yes,no
231 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DAYTIME SYMPTOMS less than twice weekly checkbox
232 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DAYTIME SYMPTOMS more than twice weekly checkbox
233 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DAYTIME SYMPTOMS daily checkbox
234 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DAYTIME SYMPTOMS,NIGHT SYMPTOMS continuous checkbox
235 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS NIGHT SYMPTOMS radio yes,no
236 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS NIGHT SYMPTOMS less than twice monthly checkbox
237 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS NIGHT SYMPTOMS more than twice monthly checkbox
238 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS NIGHT SYMPTOMS nightly checkbox
239 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DURING OR AFTER EXERCISE radio yes,no
240 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DURING OR AFTER EXERCISE exercise symptoms may occur checkbox
241 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DURING OR AFTER EXERCISE less than once weekly checkbox
242 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DURING OR AFTER EXERCISE frequent exercise symptoms checkbox
243 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS DURING OR AFTER EXERCISE significant limitation activity checkbox
244 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS EXTRA ALBUTEROL USE radio yes,no
245 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS EXTRA ALBUTEROL USE occasional use checkbox
246 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS EXTRA ALBUTEROL USE periods of daily use checkbox
247 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS EXTRA ALBUTEROL USE daily use checkbox
248 ALLERGY/ASTHMA COUGH OR WHEEZE SYMPTOMS EXTRA ALBUTEROL USE frequent daily need checkbox
249 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) radio yes,no
250 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: radio yes,no
251 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: colds/infection checkbox
252 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: morning checkbox
253 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: night checkbox
254 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: exercise checkbox
255 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: cold air checkbox
256 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: outdoors checkbox
257 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: paint fumes checkbox
258 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: changes in humidity checkbox
259 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: school/work environment checkbox
260 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: allergies checkbox
261 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: stress checkbox
262 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: second hand smoke checkbox
263 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: tobacco use checkbox
264 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: perfume/aerosol sprays checkbox
265 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: mile run time checkbox
266 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) TRIGGERS OF COUGH OR WHEEZE: pneumonia/bronchitis checkbox
267 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most) MONTHS OF SYMPTOMS: radio yes,no
268 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 10 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS January checkbox
269 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 11 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS February checkbox
270 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 12 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS March checkbox
271 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 13 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS April checkbox
272 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 14 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS May checkbox
273 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 15 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS June checkbox
274 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 16 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS July checkbox
275 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 17 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS August checkbox
276 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 18 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS September checkbox
277 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 19 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS October checkbox
278 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 20 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS November checkbox
279 ALLERGY/ASTHMA Please rank how severe symptoms are from 1-10 (1 the least and 21 the most),ALLERGY - LIKE SYMPTOMS MONTHS OF SYMPTOMS,MONTHS OF ALLERGY SYMPTOMS December checkbox
280 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS radio yes,no
281 ALLERGY/ASTHMA UPPER RESPIRATORY SYMPTOMS radio yes,no
282 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS UPPER RESPIRATORY SYMPTOMS sneezing checkbox
283 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS UPPER RESPIRATORY SYMPTOMS sniffing/drippy nose checkbox
284 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS UPPER RESPIRATORY SYMPTOMS itchy eyes/nose checkbox
285 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS UPPER RESPIRATORY SYMPTOMS dark circles under eyes checkbox
286 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS UPPER RESPIRATORY SYMPTOMS sinus infection checkbox
287 ALLERGY/ASTHMA ,Neurology ALLERGY - LIKE SYMPTOMS UPPER RESPIRATORY SYMPTOMS mouth breathing/snoring checkbox
288 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS UPPER RESPIRATORY SYMPTOMS congestion checkbox
289 ALLERGY/ASTHMA, Oncology, Neurology ALLERGY - LIKE SYMPTOMS UPPER RESPIRATORY SYMPTOMS headaches checkbox
290 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS OTHER text
291 ALLERGY/ASTHMA ,Neurology ALLERGY - LIKE SYMPTOMS OTHER eczema checkbox
292 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS OTHER hives checkbox
293 ALLERGY/ASTHMA ,Neurology ALLERGY - LIKE SYMPTOMS OTHER dry skin checkbox
294 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS OTHER itchy skin checkbox
295 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS OTHER ear infection checkbox
296 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS OTHER nausea checkbox
297 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS OTHER dry cough checkbox
298 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS OTHER throat clearing checkbox
299 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES radio yes,no
300 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES Smoke checkbox
301 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES fireplace/woodstove checkbox
302 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES animals checkbox
303 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES feather (pillows, stuffed animals) checkbox
304 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES carpeting checkbox
305 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES bedroom carpeting checkbox
306 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES forced air heat checkbox
307 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES mold in lower level checkbox
308 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES humidifier/vaporizer checkbox
309 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES bedroom in lower level checkbox
310 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES rural checkbox
311 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES city checkbox
312 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS EXPOSURES suburbs checkbox
313 ALLERGY/ASTHMA , Urology ALLERGY - LIKE SYMPTOMS ENVIRONMENTAL CONTROLS radio yes,no
314 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS ENVIRONMENTAL CONTROLS air conditioning checkbox
315 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS ENVIRONMENTAL CONTROLS HEPA filter checkbox
316 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS ENVIRONMENTAL CONTROLS dehumidifier checkbox
317 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS ENVIRONMENTAL CONTROLS wood floors checkbox
318 ALLERGY/ASTHMA ALLERGY - LIKE SYMPTOMS ENVIRONMENTAL CONTROLS mattress & pillow covers checkbox
319 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: TESTING/EVALUATION/EDUCATION: Has the patient ever had a breathing/lung function test? radio yes,no
320 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Has the patient ever had a breathing/lung function test? If yes, when? text yes,no
321 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Do you have an action plan at school/daycare? radio yes,no
322 ALLERGY/ASTHMA Please check those items which trigger your child’s allergy or asthma symptoms checkbox Dust,Cold Air,Exercise,Viral Infection,Ear or Sinus Infections,Weather Changes,Pollens,Cigarette Smoke,Strong odors,Cats,Dogs
323 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Has the patient ever had allergy testing? radio yes,no
324 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Has the patient had their flu vaccine this year? radio yes,no
325 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Has the patient ever had flu vaccine? radio yes,no
326 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Do you have an action plan at home? radio yes,no
327 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Do you have any questions about your action plan? radio yes,no
328 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Have you received asthma information? radio yes,no
329 ALLERGY/ASTHMA TESTING/EVALUATION/EDUCATION: Would you like more information? radio classes,reading material,websites
330 Cardiology Personal History radio yes,no
331 Cardiology,Oncology,Neurology Personal History Dizziness or fainting radio Within last 30 days,In the past
332 Cardiology,Neurology Personal History Falls that caused an injury radio Within last 30 days,In the past
333 Cardiology Personal History Stroke radio Within last 30 days,In the past
334 Cardiology Personal History Shortness of breath when walking 1 to 2 blocks radio Within last 30 days,In the past
335 Cardiology Personal History Shortness of breath when climbing 1 flight of stairs radio Within last 30 days,In the past
336 Cardiology Personal History Shortness of breath when lying down radio Within last 30 days,In the past
337 Cardiology,Neurology,Urology Personal History Lower leg cramps while walking radio Within last 30 days,In the past
338 Cardiology Personal History Bleeding problems or low iron (also called anemia) radio Within last 30 days,In the past
339 Cardiology Personal History Blood clot in leg (also called phlebitis) radio Within last 30 days,In the past
340 Cardiology,Neurology Personal History High cholesterol radio Within last 30 days,In the past
341 Cardiology Personal History Diabetes radio Within last 30 days,In the past
342 Cardiology Personal History High blood pressure radio Within last 30 days,In the past
343 Cardiology,Neurology Personal History Heart murmur or abnormal heart valve radio Within last 30 days,In the past
344 Cardiology Personal History Uncomfortable feeling in the chest radio Within last 30 days,In the past
345 Cardiology,Neurology Personal History Chest pain with activity (also called angina) radio Within last 30 days,In the past
346 Cardiology Personal History Heart attack (also called myocardial infarction) radio Within last 30 days,In the past
347 Cardiology Personal History Swollen legs radio Within last 30 days,In the past
348 Cardiology Personal History ankles or feet radio Within last 30 days,In the past
349 Cardiology,Oncology Personal History Irregular heartbeat radio Within last 30 days,In the past
350 Cardiology Have you had any of the following tests or procedures radio yes,no
351 Cardiology Have you had any of the following tests or procedures Stress test or treadmill test: radio
352 Cardiology Have you had any of the following tests or procedures Cardiac catheterization or angiogram: radio
353 Cardiology Have you had any of the following tests or procedures Angioplasty or stent radio
354 Cardiology,Neurology Have you had any of the following tests or procedures Heart surgery If so, what kind? radio yes,no
355 Cardiology Have you had any of the following tests or procedures Heart surgery If so, what kind? please explain text
356 Cardiology Do you follow a special meal plan or diet (such as Atkins®, Weight Watchers®, vegetarian, low fat, or diabetic)? radio yes,no
357 Cardiology Do you follow a special meal plan or diet (such as Atkins®, Weight Watchers®, vegetarian, low fat, or diabetic)? If YES, which meal plan or diet do you follow? text
358 Cardiology Do you exercise regularly? radio yes,no
359 Cardiology Do you exercise regularly? If YES, how many days a week? text
360 Oncology,Neruology Fever over 100 degrees F checkbox
361 Oncology,Neurology Bone pain checkbox
362 Oncology,Neruology Joint pain or stiffness checkbox
363 Oncology Lumps under the skin checkbox
364 Oncology New spots checkbox
365 Oncology Sores that won’t heal checkbox
366 Oncology Yellowing of eyes or skin (jaundice) checkbox
367 Oncology Serious cough that brings up a lot of mucus or phlegm checkbox
368 Oncology,Neruology Weakness in hand, arm, or leg checkbox
369 Oncology Problems with balance checkbox
370 Oncology Dry mouth checkbox
371 Oncology Problems chewing checkbox
372 Oncology Problems swallowing checkbox
373 Oncology Problems remembering things checkbox
374 Oncology Hard time finding the right word checkbox
375 Oncology Hard time concentrating checkbox
376 Oncology,Neruology Double vision checkbox
377 Oncology Sudden need to urinate checkbox
378 Oncology,urology Leaking urine checkbox
379 Oncology Are you having pain now? radio yes,no
380 Oncology Are you having pain now? If YES, where is your pain? text
381 Oncology How often are you in pain? text
382 Oncology When did your pain start? text
383 Oncology How would you describe your pain on a scale from 0 to 10, with 0 being no pain and 10 being worst pain ever? radio 0 ,1, 2, 3, 4, 5, 6, 7, 8, 9,10
384 Oncology Are you controlling your pain with medicine? radio yes,no
385 Oncology Are you controlling your pain with medicine? If YES, what pain medicine do you take? text
386 Oncology How often do you take this pain medicine? text
387 Oncology Do you live in an Assisted Living Facility, Adult Family Home, Nursing Home? radio yes,no
388 Oncology May we give information about your health to another person? radio yes,no
389 Oncology May we give information about your health to another person? Name of person text
390 Oncology May we give information about your health to another person? Relationship to you text
391 Oncology Does anyone from Home Health or Hospice visit you at home? radio yes,no
392 Oncology Have you been able to continue most of your normal activities? radio yes,no
393 Neurology Atrial fibrillation checkbox
394 Neurology Bowel Problems checkbox
395 Neurology Crohn’s Disease checkbox
396 Neurology Loss of consciousness text
397 Neurology Parkinson’s Disease checkbox
398 Neurology Fibromyalgia checkbox
399 Neurology Stomach Ulcers text
400 Neurology Neck Surgery checkbox
401 Neurology Back Surgery checkbox
402 Neurology Aneurysm Surgery checkbox
403 Neurology Abdominal Surgery checkbox
404 Neurology Bowel Surgery checkbox
405 Neurology Bypass in the legs checkbox
406 Neurology Gallbladder Surgery checkbox
407 Neurology Gastric bypass surgery checkbox
408 Neurology Gynecologic surgery checkbox
409 Neurology Implants Type text
410 Neurology Intrathecal Pump checkbox
411 Neurology Pacemaker Surgery checkbox
412 Neurology Stimulator checkbox
413 Neurology Use caffeine checkbox
414 Neurology Street Drug text
415 Neurology Dementia radio yes,no
416 Neurology Epilepsy radio yes,no
417 Neurology Migraine Headaches radio yes,no
418 Neurology Polyneuropathy radio yes,no
419 Neurology Tremor radio yes,no
420 Neurology Poor memory checkbox
421 Neurology Difficulty finding words checkbox
422 Neurology Frequent sore throat checkbox
423 Neurology Hoarseness checkbox
424 Neurology Discharge from nose checkbox
425 Neurology Repeated sinus infections checkbox
426 Neurology Palpitations checkbox
427 Neurology Irregular heart beat checkbox
428 Neurology Cold hands checkbox
429 Neurology Cold feet checkbox
430 Neurology Chronic cough checkbox
431 Neurology Muscle loss checkbox
432 Neurology,urology Excessive thirst checkbox
433 Neurology Farsighted checkbox
434 Neurology Nearsighted checkbox
435 Neurology Changes in hair checkbox
436 Neurology Changes in nails checkbox
437 Neurology Changes in skin color checkbox
438 Neurology Dry skin checkbox
439 Dermatology Over the last week, how itchy, sore,painful or stinging has your skin been? radio Very much,A lot,A little, Not at all
440 Dermatology Over the last week, how embarrassed or self conscious have you been because of your skin? radio Very much,A lot,A little, Not at all
441 Dermatology Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden? radio Very much,A lot,A little, Not at all
442 Dermatology Over the last week, how much has your skin influenced the clothes you wear? radio Very much,A lot,A little, Not at all
443 Dermatology Over the last week, how much has your skin affected any social or leisure activities? radio Very much,A lot,A little, Not at all
444 Dermatology Over the last week, how much has your skin made it difficult for you to do any sport? radio Very much,A lot,A little, Not at all
445 Dermatology Over the last week, has your skin prevented you from working or studying? radio yes,no
446 Dermatology If "No", over the last week how much has your skin been a problem at work or studying? radio A lot,A little,Not at all
447 Dermatology Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives? radio Very much,A lot,A little, Not at all
448 Dermatology Over the last week, how much has your skin caused any sexual difficulties? radio Very much,A lot,A little, Not at all
449 Dermatology Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time? radio Very much,A lot,A little, Not at all
450 Urology Are you interested in smoking cessation counseling? radio yes,no
451 Urology Living Will or Power of Attorney checkbox
452 Urology Living Will or Power of Attorney checkbox
453 Urology Surrogate Designation (name/relation) text
454 Medical History, Family history,Urology Anesthesia Problems checkbox
455 Medical History, Family history,Urology Urolithiasis (Urinary Stones) checkbox
456 Urology extreme and insatiable hunger checkbox
457 Urology genital pain checkbox
458 Urology the sensation of pain and/or burning checkbox
459 Urology Urinary incontinence problem checkbox
460 Urology Genital Sore checkbox

4
storage/questionere profile sample sheet - Sheet2.csv Normal file
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@@ -0,0 +1,4 @@
bp_match,c,exact_match,e
0,100,yes,100
60,80,no,0
70,60,high,100
1 bp_match c exact_match e
2 0 100 yes 100
3 60 80 no 0
4 70 60 high 100

BIN
storage/questionere profile sample sheet.xlsx Normal file
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