Study – Winston Salem, March of 2009

Volunteer’s.Health.Form Form ID #
9087

 Male
 Female
Age _________ *Optional

PAIN when perceived last extent

Head, headaches, migraine current | within a week ago | longer ago 1 2 3 4 5
Throat or front of neck  current | within a week ago | longer ago 1 2 3 4 5
Back of neck  current | within a week ago | longer ago 1 2 3 4 5
Left shoulder  current | within a week ago | longer ago 1 2 3 4 5
Right shoulder  current | within a week ago | longer ago 1 2 3 4 5
Left arm  current | within a week ago | longer ago 1 2 3 4 5
Right arm  current | within a week ago | longer ago 1 2 3 4 5
Left hand or left wrist  current | within a week ago | longer ago 1 2 3 4 5
Right hand or right wrist  current | within a week ago | longer ago 1 2 3 4 5
Chest area  current | within a week ago | longer ago 1 2 3 4 5
Upper abdomen  current | within a week ago | longer ago 1 2 3 4 5
Left side of abdomen  current | within a week ago | longer ago 1 2 3 4 5
Right side of abdomen  current | within a week ago | longer ago 1 2 3 4 5
Lower abdomen  current | within a week ago | longer ago 1 2 3 4 5
Hip or pelvic area  current | within a week ago | longer ago 1 2 3 4 5
Upper back  current | within a week ago | longer ago 1 2 3 4 5
Middle back  current | within a week ago | longer ago 1 2 3 4 5
Lower back  current | within a week ago | longer ago 1 2 3 4 5
Left leg  current | within a week ago | longer ago 1 2 3 4 5
Right leg  current | within a week ago | longer ago 1 2 3 4 5
Left knee  current | within a week ago | longer ago 1 2 3 4 5
Right knee  current | within a week ago | longer ago 1 2 3 4 5
Left foot  current | within a week ago | longer ago 1 2 3 4 5
Right foot  current | within a week ago | longer ago 1 2 3 4 5
Heart  current | within a week ago | longer ago 1 2 3 4 5
Stomach  current | within a week ago | longer ago 1 2 3 4 5
Other pain  current | within a week ago | longer ago 1 2 3 4 5
Write area of the other pain:

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 Study – Winston Salem, March of 2009
Volunteer’s.Health.Form Form ID #
9087
JOINT PROBLEMS when perceived last extent
defined as reduced mobility of a joint
joint that locks, and/or has pain
Jaw  current | within a week ago | longer ago 1 2 3 4 5
Neck  current | within a week ago | longer ago 1 2 3 4 5
Left Shoulder  current | within a week ago | longer ago 1 2 3 4 5
Right Shoulder  current | within a week ago | longer ago 1 2 3 4 5
Left Elbow  current | within a week ago | longer ago 1 2 3 4 5
Right Elbow  current | within a week ago | longer ago 1 2 3 4 5
Left Wrist  current | within a week ago | longer ago 1 2 3 4 5
Right Wrist  current | within a week ago | longer ago 1 2 3 4 5
Left hand Fingers  current | within a week ago | longer ago 1 2 3 4 5
Right hand Fingers  current | within a week ago | longer ago 1 2 3 4 5
Spine  current | within a week ago | longer ago 1 2 3 4 5
Left side Hip/Thigh joint  current | within a week ago | longer ago 1 2 3 4 5
Right side Hip/Thigh joint  current | within a week ago | longer ago 1 2 3 4 5
Left Knee  current | within a week ago | longer ago 1 2 3 4 5
Right Knee  current | within a week ago | longer ago 1 2 3 4 5
Left Ankle  current | within a week ago | longer ago 1 2 3 4 5
Right Ankle  current | within a week ago | longer ago 1 2 3 4 5
Left Foot or Toes  current | within a week ago | longer ago 1 2 3 4 5
Right Foot or Toes  current | within a week ago | longer ago 1 2 3 4 5

BONE PROBLEMS when perceived last extent

defined as pain, reduced function etc.
Cranium current | within a week ago | longer ago 1 2 3 4 5
Neck vertebrae, collar bone current | within a week ago | longer ago 1 2 3 4 5
Upper back spine current | within a week ago | longer ago 1 2 3 4 5
Middle back spine current | within a week ago | longer ago 1 2 3 4 5
Lower back spine current | within a week ago | longer ago 1 2 3 4 5
Chest, ribcage current | within a week ago | longer ago 1 2 3 4 5
Left side Hip and pelvic current | within a week ago | longer ago 1 2 3 4 5
Right side Hip and pelvic current | within a week ago | longer ago 1 2 3 4 5
Left Shoulder current | within a week ago | longer ago 1 2 3 4 5
Right Shoulder current | within a week ago | longer ago 1 2 3 4 5
Left arm or hand current | within a week ago | longer ago 1 2 3 4 5
Right arm or hand current | within a week ago | longer ago 1 2 3 4 5
Left leg or foot current | within a week ago | longer ago 1 2 3 4 5
Right leg or foot current | within a week ago | longer ago 1 2 3 4 5

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 Study – Winston Salem, March of 2009
Volunteer’s.Health.Form Form ID #
9087
SPECIAL CONDITIONS when or where extent
Fractured bone most recent  recent | month | 6 months | year | longer 1 2 3 4 5
What bone was fractured scull, neck | left arm, hand | right arm, hand
and the extent of the fracture: collarbone | rib | spine | hip | L leg | R leg
Is there any remaining discomfort or 1 2 3 4 5
damage after the fracture, describe:
Have you had surgeries, which 
Implants, screws, staples, after surgery:
Large scars and where  1 2 3 4 5
Removed organs  kidney | gall bladder | appendix | tonsils
Missing your own natural… upper jaw left side | upper jaw right side
tooth or teeth in what area(s)  lower jaw left side | lower jaw right side
Do you exercise, how often  daily | weekly | monthly | few times a year 1 2 3 4 5
Heart problem  now | past week | month | year | longer 1 2 3 4 5
(Women) Pregnant  few days | month | 2-5 months | 6-9 months
(Men) Vasectomy 

DISCOMFORTS when or where extent

Permanent ”objects” in field of vision left eye | right eye | both eyes 1 2 3 4 5
Describe shape, placement, and size:
Bad hearing in Left ear  1 2 3 4 5
Bad hearing in Right ear  1 2 3 4 5
Tinnitus (ringing in Left ear)  1 2 3 4 5
Tinnitus (ringing in Right ear)  1 2 3 4 5
Dizziness  current | within a week ago | longer ago 1 2 3 4 5
Confusion  current | within a week ago | longer ago 1 2 3 4 5
Anxiety  current | within a week ago | longer ago 1 2 3 4 5
Hands get cold due to circulation  current | within a week ago | longer ago 1 2 3 4 5
Feet get cold due to circulation  current | within a week ago | longer ago 1 2 3 4 5
Asthma  current | within a week ago | longer ago 1 2 3 4 5
Cough  current | within a week ago | longer ago 1 2 3 4 5
Phlegm in respiratory system or lungs  current | within a week ago | longer ago 1 2 3 4 5
Low oxygen uptake  current | within a week ago | longer ago 1 2 3 4 5
Do you smoke (when last)  current | within a week ago | longer ago 1 2 3 4 5
Numbness, loss of sensation  current | within a week ago | longer ago 1 2 3 4 5
Which body part becomes numb:
Kidney stones  current | within a week ago | longer ago 1 2 3 4 5
Gall stones  current | within a week ago | longer ago 1 2 3 4 5
Trouble swallowing  current | within a week ago | longer ago 1 2 3 4 5
Need to use restroom now  1 2 3 4 5

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 Study – Winston Salem, March of 2009
Volunteer’s.Health.Form Form ID #
9087
MUSCLE PROBLEMS when or where extent
defined as cramp,
significantly tense, pain
Facial/Head current | within a week ago | longer ago 1 2 3 4 5
Neck current | within a week ago | longer ago 1 2 3 4 5
Shoulders/Shoulderblades/Upper back current | within a week ago | longer ago 1 2 3 4 5
Chest current | within a week ago | longer ago 1 2 3 4 5
Upper back current | within a week ago | longer ago 1 2 3 4 5
Middle back/Lower back current | within a week ago | longer ago 1 2 3 4 5
Abdomen current | within a week ago | longer ago 1 2 3 4 5
Left arm/hand current | within a week ago | longer ago 1 2 3 4 5
Right arm/hand current | within a week ago | longer ago 1 2 3 4 5
Left leg/foot current | within a week ago | longer ago 1 2 3 4 5
Right leg/foot current | within a week ago | longer ago 1 2 3 4 5

DESCRIPTIONS *OPTIONAL PART!

List three of the most significant discomforts that you have with your body. They may already be
accounted for in the questions above but here you can mention them again with a description. If
there are more than three discomforts, only list the three most significant ones. Discomforts are
defined as something you feel and are aware of that gets your attention from time to time and
makes you uncomfortable. Such as a painful knee, blurry vision, difficulty hearing, a cramp in a
muscle, or anything else that “doesn’t work” the way it should and that bothers you.
1. The most significant discomfort
What part of the body: current | within a week ago | longer ago 1 2 3 4 5
Describe:______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. The second most significant discomfort
What part of the body: current | within a week ago | longer ago 1 2 3 4 5
Describe:______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. The third most significant discomfort
What part of the body: current | within a week ago | longer ago 1 2 3 4 5
Describe:______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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