purityselect/storage/question data (5).csv

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