ReCHARGE with Strawberries - Health History Questionnaire


**DO NOT submit questionnaire if you were found to be ineligible for the study**


 

Thank you for your time and participation. At this time, you are not eligible to complete the health history questionnaire.

(mm/dd/year)
A. MENSTRUAL CYCLE HISTORY
years, months
B. WEIGHT HISTORY
ft, in
years/months/weeks
C. DIET HISTORY

b. please indicate below how many drinks and the type of drinks you typically consume in a week:

fluid ounces (12 fl oz is 1 can of beer)
fluid ounces (5 fluid oz is a glass of wine)
fluid ounces (1.5 fluid oz is one shot)

Please indicate below how much of each type of drink you consume in an average day (1cup=8oz):

cups/day
cups/day
fluid ounces (1 can=12oz; fountain drinks vary from 8-32oz)

What two beverages do you currently drink most frequently?

D. PHYSICAL ACTIVITY HISTORY

The following question relates to your physical activity. Please refer to the information below when answering this question.

*

Low= requires minimal to no effort with no change in heart rate e.g. walking slowly, sitting at computer, standing light work (cooking, washing dishes), stretching, fishing, playing catch, light yard/house work

Mod= requires a moderate amount of effort and causes increased breathing with a moderate increase in heart rate e.g. walking briskly, heavy cleaning (washing windows, vacuuming, mopping), mowing lawn, bicycling lightly, hiking, recreational swimming.

High= requires a large amount of effort and causes rapid breathing and a substantial increase in heart rate e.g. jogging/running, mountain climbing, bicycling more than 10mph, step aerobics, jump roping, treading water.

If YES, please complete the following information regarding your regular physical activity/exercise routine. (separate answers with commas, e.g. walking, 30 minutes, 2 times, low)

Activity                    Timer per occasion        Times Per Week      Intensity

example:walking     30 minutes                     2 times                   *low, mod. or high?

E. PHYSICAL ASSESSMENT
NOYES
a. Pneumonia *
b. Collapsed Lung *
c. Emphysema *
d. Tuberculosis *
e. Chronic Bronchitis *
f. Asthma *
g. Allergies *
h. Other respiratory problems *
NOYES
a. Heart Attack *
b. Hypertension (high blood pressure) *
c. Hypotension (low blood pressure) *
d. Angina (chest pain) *
e. Shortness of breath *
f. Other heart problems: *
NOYES
a. Hepatitis *
b. Liver disease *
c. Ulcerative colitis/regional enteritis (Crohn's disease) *
d. Diverticulosis/Diverticulitis *
e. Gallbladder disease *
f. Hemorrhoids *
g. Pancreatitis *
h. Inflammatory bowel disease *
i. Peptic/duodenal ulcer *
j. Spastic colon (irritable bowel disease) *
k. Colon polyps *
l. Dysphagia (Difficulty swallowing) *
m. Other Gastrointestinal problems: *
NOYES
a. Type I Diabetes *
b. Type II Diabetes *
c. Hyperthyroid (overactive thyroid) *
d. Hypothyroid (underactive thyroid) *
e. Gout *
f. High blood cholesterol/triglycerides/lipids *
g. Elevated blood sugar/insulin resistance/'pre-diabetic' *
h. Other metabolic/endocrine condition: *
NOYES
a. Stroke *
b. Parkinson's disease *
c. Seizures *
d. Other neurological disorders: *
NOYES
a. Depression *
b. Substance abuse *
c. Cancer *
d. Food allergies *
e. Vision problems *
f. Hormone replacement therapy *
g. Blood disorder *

*Please Note: All information obtained in this health history questionnaire will remain CONFIDENTIAL.

Thank you!


 

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