Questionnaire

If you are interested in seeing if you qualify for one of our studies, please complete the questionnaire below. We will contact you to discuss our upcoming studies and if you might be a good fit for Midwest Clinical Research.

Midwest Clinical Research, L.L.C.

Study Patient History

Patient Name:
Age:
Primary Physician:
Name:
Address:
City:
State:
Zip Code:

Current Allergy/Asthma Symptoms

Symptoms

Yes	No	Cough
Yes	No	Wheeze
Yes	No	Tight Chest
Yes	No	Shortness of breath
Yes	No	Fatigue

Nasal Symptoms

Yes	No	Nasal drainage
Yes	No	Sneezing
Yes	No	Stuffy nose
Yes	No	Roof of your mouth itch
Yes	No	Sinus headaches

Eye Symptoms

Yes	No	Itching
Yes	No	Watering
Yes	No	Redness
Yes	No	Puffiness

Ear Symptoms

Yes	No	Itching
Yes	No	Infections

Skin Symptoms

Yes	No	Hives
Yes	No	Rashes
Yes	No	Eczema
Yes	No	Psoriasis

Allergy/Asthma Triggers

Which of the following trigger symptoms?

Yes	No	Certain times of year
		If so, which symptoms?
Yes	No	Open windows
Yes	No	Animals
		If so, which ones?
Yes	No	Cutting grass
Yes	No	Foods
		If so, which ones?
Yes	No	House dust/vacuuming
Yes	No	Damp, musty areas
Yes	No	Cold air
Yes	No	Exercise
Yes	No	Irritants (perfumes, aerosol)

Medical History

Have you had in the last 3 months:

Yes	No	Bronchitis
Yes	No	Pneumonia
Yes	No	Sinus Infection

Have you ever been diagnosed with:

Yes	No	Emphysema
Yes	No	Exposure to tuberculosis
Yes	No	Positive TB skin test
Yes	No	Other lung diseases
Yes	No	Heart problems
Yes	No	Heart attack
Yes	No	High blood pressure
Yes	No	High cholesterol
Yes	No	Diabetes
Yes	No	Kidney disease
Yes	No	Liver disease
Yes	No	Cancer
Yes	No	Blood disease
Yes	No	Anemia
Yes	No	Osteoporosis
Yes	No	Bone fractures
Yes	No	Stomach problems
Yes	No	Ulcers
Yes	No	Hernias
Yes	No	Disease of the eye
Yes	No	Cataracts
Yes	No	Glaucoma
Yes	No	Seizures
Yes	No	Are you allergic or sensitive to any medications?
		If so, which ones?

Medical/Allergy Testing, Hospitalizations & Surgeries

Have you had:

Yes	No	Chest X-Ray
		If so, date of most recent:
		Where was the test done?
		Results:
Yes	No	Allergy testing
		If so, date of most recent:
		Where was the test done?
		Results:
Yes	No	Allergy shots
		If so, date of most recent:
		Where was the test done?
		Results:
Yes	No	Pulmonary function testing
		If so, date of most recent:
		Where was the test done?
		Results:
		If you have received Prednisone by mouth, when was the last time?
Yes	No	Any other medical conditions?
		If so, list and give start dates, current treatments
Yes	No	Have you ever had major surgery?
		If so, list reasons/procedures/dates:

Additional History

Family History

Yes	No	Do other family members have asthma, allergies, sinus problems or frequent infections?
		If so, who:

Animals/Pets

Yes	No	Do you have indoor pets?
		If so, what kind?

If male, postmenopausal, or a child, please skip to next section.

Pregnancy

Yes	No	Are you currently pregnant?
Yes	No	Are you planning a pregnancy?
Yes	No	Are you currently breastfeeding?
		Type of contraception:

Smoking and alcohol use

Yes	No	Do you drink alcoholic beverages?
		If yes, how many drinks per day?
Yes	No	Do you currently smoke?
		If yes, for how many years?
Yes	No	Have you smoked in the past?
		If yes, when did you quit?
		How many cigarettes daily or how many packs a day?
Yes	No	Does anyone in your home smoke?

Coordinator: figure pack years
Packs per day x years smoked = pack years
OR
# cigs a day/20 x years smoked = pack years

Demographics Questionnaire

First Name:
MI:
Last Name:
Birthday:
Age:
Race:
Parent’s Name (if minor):
Address:
City:
State:
Zip Code:
Home Phone:
Cell phone:
Work Phone:
Emergency Contact Name:
Relationship:
Emergency Contact’s Phone:

Yes

I would like to be notified of future studies.