Medical Checklist
Participant ID
Assessment Type
Please select...
Pre
Do any of the following physical problems currently interfere with your functioning?
1. Alcohol addiction
Yes
No
2. Asthma or allergies
Yes
No
3. Back pain
Yes
No
4. Cancer/tumor
Yes
No
(if yes, what type?)
5. Cardiac/heart problems
Yes
No
6. Convulsions, seizures or epilepsy
Yes
No
7. Dental problems
Yes
No
8. Diabetes
Yes
No
9. Drug addiction
Yes
No
10. Eating disorder
Yes
No
11. Gynecological problems
Yes
No
12. Headaches (including migraines)
Yes
No
13. Hearing problems
Yes
No
14. High blood pressure
Yes
No
15. High cholesterol
Yes
No
16. Kidney disease
Yes
No
17. Neurological problems
Yes
No
18. Pneumonia
Yes
No
19. Prescription medication abuse or addiction
Yes
No
20. Self-harm/cutting
Yes
No
21. STDs (Sexually Transmitted Diseases)
Yes
No
22. Stomach problems
Yes
No
23. Swelling
Yes
No
24. Sleep problems
Yes
No
25. Thyroid disorders
Yes
No
(if yes, type?)
26. Tobacco use (including chewing tobacco)
Yes
No
27. Vision problems
Yes
No
Have you ever:
28. Had a serious problem with alcohol use?
Yes
No
29. Received alcohol treatment?
Yes
No
30. Had a serious problem with drug use?
Yes
No
31. Had a serious problem with prescription medication abuse?
Yes
No
32. Received drug treatment?
Yes
No
33. Received psychological treatment?
Yes
No
34. Been severely physically scarred?
Yes
No
35. Had a head injury?
Yes
No
36. Been disabled from work?
Yes
No
If yes, what is the date you last worked?
37. Are you currently pregnant?
Yes
No
Enter the NUMBER
38. Current weight (in pounds)
39. Current height
40. Number of surgeries (including Cesarean sections)
41. Number of pregnancies
42. Number of pregnancies with complications
43. Number of miscarriages
44. If you smoke, number of cigarettes per day
45. Number of cups of coffee/caffeinated drinks per day
46. Select illegal drugs you have used: (hold down the Ctrl key to select more than one)
Please select...
Marijuana
Methamphetamine
Cocaine
Heroin
Mushrooms
PCP
LSD (acid)
None
Other(s)
Other:
47. List prescription medications you currently take:
48. List prescription medications you took previously: (if you can't remember specific prescriptions names, please list categories of medications - i.e. antidepressants, pain management medication, etc.)
Comments about current/past medical information
Contact Information