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subjectInitial Health History Form

You must log in with your NetID to submit this form.$

Namewidth: 250pxfrom-nametext$user.fullNametrue

Examinee Email Address:width: 250pxfromtext$user.emailtrue

Principal Investigator:width: 250pxPrincipalInvestigatortexttrue

Choose OneFieldStudiesFishFrogsOtherRodents5Assign:falseField StudiesFish/FrogsOtherAssignRodents

mediumFieldfalsewidth: 500pxFieldStudiesDetails0Details:4 false

Choose OneNoNoWorkedWithAnimalsYesYes31. Have you worked with animals before?false

mediumFieldfalsewidth: 500pxWorkedWithAnimalsDetails0Details:4 false

Choose OneNoNoHavePetsYesYes32. Do you have pets?false

Choose OneNoNoCloseContactsAnimalsYesYes33. Do any of your close personal contacts (family, friends, significant others) work with animals, or do they have pets?false

Choose OneNoNoIllnessFromAnimalsYesYes34. Have you, to your knowledge, ever had an illness as a result of exposure to animals?false

Choose OneNoNoHadAsthmaYesYes35. Have you had asthma?false

Choose OneNoNoTakeAsthmaMedsYesYes35a. Do you take asthma medications?false

If you are using a "rescue" inhaler, how often have you used it in the last month?width: 250pxRescueInhalerLastMonthUsagetext

Choose OneNoNoHospitalERAsthmaFiveYearsYesYes35b. Have you been hospitalized or been seen in the emergency room because of asthma in the last five years?false

Choose OneNoNoSteroidsFiveYearsYesYes35c. Have you taken steroids (prednisone) for asthma in the last five years?false

6. Have you had any of the following symptoms, not associated with a cold or flu, in the last 5 years?

DailyNeverDailyWeeklyWeeklyNeverWateryItchyEyesMonthlyMonthly4Watery, Itchy eyes:false

DailyNeverDailyWeeklyWeeklyNeverRunnyStuffyNoseMonthlyMonthly4Runny, stuffy, nose:false

DailyNeverDailyWeeklyWeeklyNeverPostNasalDripMonthlyMonthly4Post-nasal drip:false

DailyNeverDailyWeeklyWeeklyNeverSneezingSpellsMonthlyMonthly4Sneezing spells:false

DailyNeverDailyWeeklyWeeklyNeverFrequentDryCoughMonthlyMonthly4Frequent dry cough:false

DailyNeverDailyWeeklyWeeklyNeverWheezingInChestMonthlyMonthly4Wheezing in chest:false

DailyNeverDailyWeeklyWeeklyNeverSkinRashMonthlyMonthly4Skin rash:false


DailyNeverDailyWeeklyWeeklyNeverSwellingThroatMonthlyMonthly4Swelling of the throat:false

Choose OneNoNoTakeMedsForOtherSymptomsYesYes36a. Do you take medications for any of these symptoms?false

Choose OneNoNoDoctorTreatedAllergiesYesYes37. Have you ever been treated by a doctor for allergies?false

Choose OneNoNoIdentifiedSubstancesTriggerYesYes38. Have you identified what substances of exposures trigger your symptoms?false

Choose OneNoNoTakeOtherMedicationYesYes39. Do you take other medication?false

mediumFieldfalseOtherMedicationsDetails09a. List other medications:4false


Choose OneNoNoOtherHealthIssuesYesYes310. Do you have other health issues?false

mediumFieldfalseOtherHealthIssuesDetails010a. List other health issues:4false


11. When was your last tetanus booster?width: 250pxLastTetanusBoostertexttrue

Choose OneHIPAAYesI have read and understand the attached HIPAA form and authorize Community Care Physicians, P.C. to use and/or disclose certain protected health information (PHI) about me to Dr. Antigone McKenna and my Principal Investigator.Yes212. HIPAA Authorization true


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