Vous êtes sur la page 1sur 4

Study – Winston Salem, April 4 2009

Claimant’s.Health.Form Form ID #
1792
Space provided to write freely your impressions and make notes!
(None of this text is considered for point calculation.)

For the claimant: If you strongly suspect additional health information that is not listed in the
questionnaire, provide it below and the participants will consider whether we approach the
volunteer to ask about this:

Page 1 of 3
Study – Winston Salem, April 4 2009
Claimant’s.Health.Form Form ID #
1792
PAIN extent JOINT PROBLEMS extent

Page 2 of 3
Study – Winston Salem, April 4 2009
Claimant’s.Health.Form Form ID #
1792
Head, headaches, migraine 1 2 3 4 5 Jaw  1 2 3 4 5
Throat or front of neck  1 2 3 4 5 Neck  1 2 3 4 5
Back of neck  1 2 3 4 5 Left Shoulder  1 2 3 4 5
Left shoulder  1 2 3 4 5 Right Shoulder  1 2 3 4 5
Right shoulder  1 2 3 4 5 Left Elbow  1 2 3 4 5
Left arm  1 2 3 4 5 Right Elbow  1 2 3 4 5
Right arm  1 2 3 4 5 Left Wrist  1 2 3 4 5
Left hand or left wrist  1 2 3 4 5 Right Wrist  1 2 3 4 5
Right hand or right wrist  1 2 3 4 5 Left hand Fingers  1 2 3 4 5
Chest area  1 2 3 4 5 Right hand Fingers  1 2 3 4 5
Upper abdomen  1 2 3 4 5 Spine  1 2 3 4 5
Left side of abdomen  1 2 3 4 5 Left side Hip/Thigh joint  1 2 3 4 5
Right side of abdomen  1 2 3 4 5 Right side Hip/Thigh joint  1 2 3 4 5
Lower abdomen  1 2 3 4 5 Left Knee  1 2 3 4 5
Hip or pelvic area  1 2 3 4 5 Right Knee  1 2 3 4 5
Upper back  1 2 3 4 5 Left Ankle  1 2 3 4 5
Middle back  1 2 3 4 5 Right Ankle  1 2 3 4 5
Lower back  1 2 3 4 5 Left Foot or Toes  1 2 3 4 5
Left leg  1 2 3 4 5 Right Foot or Toes  1 2 3 4 5
Right leg  1 2 3 4 5
Left knee  1 2 3 4 5 BONE PROBLEMS extent
Right knee  1 2 3 4 5 Cranium 1 2 3 4 5
Left foot  1 2 3 4 5 Neck vertebrae, collar bone 1 2 3 4 5
Right foot  1 2 3 4 5 Upper back spine 1 2 3 4 5
Heart  1 2 3 4 5 Middle back spine 1 2 3 4 5
Stomach  1 2 3 4 5 Lower back spine 1 2 3 4 5
Other pain, write where  1 2 3 4 5 Chest, ribcage 1 2 3 4 5
Left side Hip and pelvic 1 2 3 4 5
MUSCLE PROBLEMS extent Right side Hip and pelvic 1 2 3 4 5
Facial/Head 1 2 3 4 5 Left Shoulder 1 2 3 4 5
Neck 1 2 3 4 5 Right Shoulder 1 2 3 4 5
Shoulders/Shoulderblades 1 2 3 4 5 Left arm or hand 1 2 3 4 5
Chest 1 2 3 4 5 Right arm or hand 1 2 3 4 5
Upper back 1 2 3 4 5 Left leg or foot 1 2 3 4 5
Middle back/Lower back 1 2 3 4 5 Right leg or foot 1 2 3 4 5
Abdomen 1 2 3 4 5
Left arm/hand 1 2 3 4 5
Right arm/hand 1 2 3 4 5
Left leg/foot 1 2 3 4 5
Right leg/foot 1 2 3 4 5
SPECIAL CONDITIONS extent
Page 3 of 3
Study – Winston Salem, April 4 2009
Claimant’s.Health.Form Form ID #
1792
Have you had a fractured bone?  Scull/Cranium recent | 6 months | older 1 2 3 4 5
Mark all that apply and mark when  Left arm or hand recent | 6 months | older 1 2 3 4 5
they were fractured and the  Right arm or hand recent | 6 months | older 1 2 3 4 5
extent (severity) of the fracture.  Collarbone recent | 6 months | older 1 2 3 4 5
 Rib recent | 6 months | older 1 2 3 4 5
 Spine/Back recent | 6 months | older 1 2 3 4 5
 Hip recent | 6 months | older 1 2 3 4 5
 Left leg or foot recent | 6 months | older 1 2 3 4 5
 Right leg or foot recent | 6 months | older 1 2 3 4 5
Have you had any accident or injury with
lasting discomfort, please describe: 1 2 3 4 5
Have you had surgeries, specify  1 2 3 4 5
Implants, pacemaker, screws, staples, 1 2 3 4 5
concealed body piercings,etc. describe:
Large scars, please write where  1 2 3 4 5
Kidney stones  1 2 3 4 5
Heart problem, describe: 1 2 3 4 5
Removed organs  left kidney | right 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
(Women) Pregnant  first month | 2-5 months | 6-9 months
(Women) Menstruation/Period  first half of period |second half of period
(Men) Vasectomy 

DISCOMFORTS extent
Any discomfort with eyes  left eye | right eye | both eyes 1 2 3 4 5
Permanent ”objects” in field of vision left eye | right eye | both eyes 1 2 3 4 5
Describe their 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
Anxiety  1 2 3 4 5
Dizziness  1 2 3 4 5
Confusion  1 2 3 4 5
Do you smoke cigarettes,how often  every day | few times a week | more seldomly 1 2 3 4 5
Phlegm in lungs  1 2 3 4 5
Asthma  1 2 3 4 5
Trouble swallowing  1 2 3 4 5
Need to empty bladder  1 2 3 4 5

Page 4 of 3