Personal and Family History Survey

Read each question carefully. Pick the best answer from the choices given. Then go to the question specified after your response. Thank you.

Francesco Giardina RD


First M.I. Last

Date of Birth    

1. How many years of education have you completed?
   Number of years between 3 and 24 

2. What is your current or previous occupation?

      2a. Select the one that applies best
      2b. Mark if doing shift work     

3. In the last five years, what was your highest weight?

4. In the last five years, what was your lowest weight?

5. What is your desired weight? (your response is optional)

6. What is your current weight?

7. What is your height without shoes?

8. Family History: Select any of the following health problems found in your immediate family (parent, brother, sister).
colorectal cancer
breast cancer
ovarian cancer
prostate cancer
high blood pressure
high cholesterol
coronary heart disease, heart attack, or coronary surgery before age 55 in men, or before 65 in women
I don't know my family history

9. Are you living alone?
 Yes (skip to question 10), if no, mark the general health status of those you live with.
a. Spouse
b. Partner
c. Infant - ( <1 year)
d. Son(s) - (child < 13)
e. Son(s) - (teen 13-20)
f. Son(s) - (adult 20+)
g. Daughter(s) - (child <13)
h. Daughter(s) - (teen 13 -20)
i. Daughter(s) - (adult 20+)
j. Other(s)

10. Personal History: Do you have any of the following conditions? Mark all that apply.
           allergies            high blood pressure
           anxiety disorder            asthma or bronchitis
           sleep disorder            diabetes
           emphysema (COPD)            high cholesterol
           heart disease            back pain
           migraine headaches            arthritis
           depression            gout
           osteoporosis            kidney disease
           skin cancer            pregnant (women)
           other cancer (specify)
           other (specify)

11. What medications are you currently taking?