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.

Fresh Perspectives Nutrition Counseling

*Required

Name

First	M.I.	Last
*Required *No Special Characters		*Required *No Special Characters

Date of Birth  *Required *Valid Date of Birth Required (format MM/DD/YYYY)

1. How many years of education have you completed?

   Number of years between 3 and 24*Please enter a whole number between 3 and 24

2. What is your current or previous occupation?

      2a. Select the one that applies best

      Full-Time Part-Time Not Working/Retired

      2b. Mark if doing shift work     

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

 (lbs)*Please enter a number

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

 (lbs)*Please enter a number

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

 (lbs)*Please enter a number

6. What is your current weight?

 (lbs)*Please enter a number

7. What is your height without shoes?

 (inches)*Please enter a number

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
	osteoporosis
	diabetes
	stroke
	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	Good Fair Poor
b. Partner	Good Fair Poor
c. Infant - ( <1 year)	Good Fair Poor
d. Son(s) - (child < 13)	Good Fair Poor
e. Son(s) - (teen 13-20)	Good Fair Poor
f. Son(s) - (adult 20+)	Good Fair Poor
g. Daughter(s) - (child <13)	Good Fair Poor
h. Daughter(s) - (teen 13 -20)	Good Fair Poor
i. Daughter(s) - (adult 20+)	Good Fair Poor
j. Other(s)	Good Fair Poor

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?