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Kentucky Medical Research Center
Personal Health History

Kentucky Medical Research Center (KMRC) will hold all information provided in confidence, and will not share this information with outside parties.

By completing and sending the form below, I permit Kentucky Medical Research Center to store my responses to this questionnaire in their database. Should I decide that I no longer want my information in the database, I am aware that I may contact the research center and my information will be destroyed. By sending the form below, I am also providing permission for the staff of the research center to contact me regarding future research studies.

Name:

last                first

Street:

City:

State:

Zip Code:

Date of Birth:

Home phone:

Cell phone:

Work phone:

Email:

Sex:

female

Do you smoke?

no



Have you ever had or are you currently being treated for:
yes no

Angina

Anxiety

Bunions

Cancer History

Cardiovascular Disease

Cholesterol or Blood Fat Problems

Constipation or Diarrhea

COPD or Lung Disease

Depression

Diabetes or High Blood Sugar

 

Eczema, Psoriasis, Acne or Other Skin Diseases

Fibromyalgia

Forgetfulness or Memory Problems

Gout or High Uric Acid

Hay Fever, Seasonal Allergies or Asthma

Headaches or Migraine Headaches

Heartburn or GERD

High Blood Pressure

Irritable Bowel Syndrome

Joint Pain

Kidney, Bladder Disease or Kidney Stones

Muscle Spasm

Osteoarthritis

Osteoporosis or Osteopenia

Overweight

Persistent Pain after a Shingles Attack

Restless Legs Syndrome

Rheumatoid Arthritis

Thyroid Disease

Trouble Sleeping

Urine Leakage, Urgency or Frequency of Urination



Women only:

yes

no

Do you have Very Heavy Periods?

Do you have Hot Flashes?

Do you have Loss of Sexual Desire?

Are you Post-Menopausal?

Do you have Tender Breasts during your Periods?



Men only:

yes

no

Do you have Erectile Dysfunction?

Do you have Premature Ejaculation?

Do you have Prostate problems?

May we contact you regarding future research studies?

Thank you very much for filling out this questionnaire.

If you know of others who would be interested in research, please direct them to our web site or have them call our office at 859-225-5672

Thank you



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