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MALE QUESTIONNAIRE - PAGE 6  You are on page 6 of 9 >     SYMPTOMS: RESPIRATORY 553.  Do you have a cough that produces mucus? Don't know No Recent problem for less than a month Problem for over a month but less than a year Problem for more than a year 554.  Do you have a cough that does not produce mucus (a 'dry cough')? Don't know No Recent problem for less than a month Problem for over a month but less than a year Problem for more than a year 555.  Do you have Chronic Obstructive Pulmonary Disease (COPD), also known as Emphysema or chronic Bronchitis? Don't know No - definitely not Mildly Moderately Severely 556.  Do you have a history of Acute Infectious Bronchitis? Symptoms may include chest pain on coughing, difficulty breathing, mild fever and a cough with mucus produced later in the course of the infection. Don't know No Recurrent problem, but no symptoms now Recurrent problem with current symptoms Current problem for the first time 557.  Do you feel worse when in moldy or musty places? No / don't know Somewhat Very much 558.  Pneumonia Never had it / don't know Probably/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 559.  Do you ever have shortness of breath that is not associated with significant exertion? In other words, do you experience a sensation of difficult or uncomfortable breathing or a feeling of not getting enough air? Don't know No Mildly / occasionally Moderately / often Serious sudden unexplained onset 560.  How easily do you become short of breath? Don't know Only with great exertion, for example sprinting With moderate exertion such as jogging Even with mild activity, such as walking Always/often - even when not active 561.  Asthma Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 562.  Do you wheeze? If you are using respiratory medication (e.g. for asthma), tell us if you wheeze when you are not using it. Don't know No, not at all Only after exercise Occasionally / slightly Much of the time / severely 563.  Sore throat / tonsillitis. How many times per year do you suffer from this? Never / rarely About once a year / average / don't know 2-3 times, mildly 2-3 times severely or more than 3 times mildly More than 3 times, severely 564.  Tuberculosis Never had it / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem 565.  Have you experienced any kind of chest pain, burning, tightness, pressure or discomfort within the past year? Don't know No Yes    More questions later... Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: SLEEP 566.  How often do you take a nap outside of normal sleeping hours? Never / don't know Once a month or less Once a week or less A few times per week Daily or almost daily 567.  Roughly how often do you yawn, on average? Never / a few times per year perhaps I'd say less than average Average / a few times per day / don't know Many times during the day Several times every hour 568.  Drowsiness. Not including after meals, do you find yourself often falling asleep in situations such as boring meetings, watching TV or while driving? Never / don't know Once a month or less Once a week or less A few times per week At least daily 569.  Do you generally become sleepy after eating? Rarely / don't know No Occasionally Often 570.  Do you have difficulty staying awake after midnight? Yes, always Usually / I only stay up for special occasions Sometimes / I'm about average / don't know No, I regularly stay up into the small hours Not at all, I'm a real "night person" 571.  How is your quality of sleep when you are able to sleep without interruption or pain? Usually broken up / difficult Sometimes broken up / difficult Average/sound / don't know Generally deep Always deep 572.  Sleep. On average, how many hours of sleep do you get per night? Fewer than 5 5 to 6 7 / don't know 8 9 or more 573.  Do you sweat at night? Only include sweating that is not the result of an overly warm environment or too many bed covers. Don't know No Only slightly Moderately, sheets are damp or moist Profusely, sheets are soaked 574.  If you suffer from night sweats (severe/drenching sweating that is not due to heat or humidity), for how long has it been a problem? Not applicable / don't know Recent onset only - less than 2 weeks' duration 2 weeks to 2 months 2 to 6 months Longer than 6 months 575.  Do you experience bizarre, vivid or nightmarish dreams? Never / don't know Occasionally Quite often, quite bad Often and awful/recurring nightmares 576.  Do you remember your dreams when you wake up? I almost always remember my dreams clearly Average - sometimes I remember / don't know I almost always forget them quickly 577.  Do you have any other sleep problems? Examples include insomnia, restless legs, snoring, apnea, other sleep disorders, grogginess and problems that are present upon waking up. Don't know No Yes    More questions later... Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: CARDIOVASCULAR 578.  Atherosclerosis. Never had it / don't know Probably had it/minor symptoms now resolved Significant symptoms now resolved Current problem Current major problem 579.  Have you had an enlarged artery called an aneurysm or experienced a ruptured aneurysm? Sometimes cerebral aneurysms are the cause of stroke, although most strokes are caused by clotting rather than by a rupturing aneurysm. Don't know No Possible enlargement being watched for progression Yes, may require surgery Yes, ruptured or required surgery 580.  Do you have Raynaud's phenomenon (extreme loss of circulation to fingers and/or toes)? No / don't know Probably had it / minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 581.  Have you been diagnosed with vasculitis? Don't know No Yes, in the past, but it is not a current problem Yes, it is a minor recurring problem Yes, it is a serious recurring problem 582.  Have you been diagnosed with phlebitis or thrombophlebitis? Don't know No, I do not have this condition Yes, but in the past only - not a current problem Yes, superficial phlebitis Yes, deep vein - thrombophlebitis 583.  Do you suffer from occasional and unusual pain that is in your chest, upper left arm, or left side of neck? No / don't know Occasionally / moderate Often / severe 584.  Does your heart sometimes race or palpitate such that you can feel it beating? No / don't know Occasionally / moderately Often / severely 585.  Have you had any kind of heart problem not mentioned above? Examples include heart attack, valve damage, enlargement, weakness, failure, pain, etc. Don't know No Yes / probably    More questions later... 586.  Do you have varicose veins? No / don't know Minor - first signs Moderate - a few, small instances Serious - many minor instances or a few major Severe - many major instances 587.  Have you had any kind of anemia? Don't know No Yes    More questions later... Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: IMMUNE SYSTEM 588.  Have you suffered from boils, abscesses or carbuncles? Never had one / don't know Probably had one/minor episode(s) now resolved Major episode(s) now resolved Current minor/occasional problem Current major/frequent problem 589.  Have you ever been diagnosed with cytomegalovirus (CMV)? No / don't know Yes 590.  Have you ever been diagnosed with Epstein-Barr virus (EBV)? Don't know No, tests were negative Yes, doctor suggested it but no testing was done Yes, tests confirmed previous infection only Yes, tests confirmed current active infection 591.  Have you been diagnosed with Candida infection anywhere in your body? Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 592.  Have you had fungal or yeast infections anywhere? No / don't know Minor in the past only, now resolved Major in the past only, now resolved Current minor problem Current major problem 593.  Have you had Coccidioidomycosis (Valley Fever)? Don't know No, tested negative In the past only Current problem, only lungs involved Current problem, disseminated 594.  Do you have a history of infections, for example skin, ear, bladder, respiratory etc.? No / almost never Average - occasionally / don't know Often - one or two per year Very often - more than two per year 595.  Have you ever been diagnosed with Lupus (SLE, Systemic Lupus Erythromatosis)? No / don't know Minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 596.  Have you ever been diagnosed with Lyme disease? No / don't know Minor episode now resolved Major episode now resolved Current minor problem Current major problem 597.  Do you generally have poor wound healing? No / don't know Moderate - healing takes longer than it should Severe - healing takes weeks/months 598.  Blood clotting problems. When you start to bleed, does it take a long time to stop? Don't know No, bleeding stops quickly (normal) It takes quite a long time Yes, definitely I have von Willebrand disease or hemophilia 599.  Have you suffered from Postviral Syndrome - a viral infection where symptoms persist for a long time? Never had it / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem 600.  Have you been diagnosed with scleroderma? Never had it / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem 601.  Have you had Shingles, also known as Varicella Zoster? Never had it / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem 602.  Have you been diagnosed with chronic thyroiditis (Hashimoto's disease)? Never had it / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem 603.  Have you had tumors that were benign, or cysts? Never had any / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem 604.  Do you have Multiple Sclerosis? Details can be entered into box below. Never had it / don't know Probably had it/minor episode now in remission Significant problem in remission for some time Current problem Current major problem 605.  Have you ever had from any form of cancer? No / don't know Yes    More questions later... Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: SKIN: GENERAL 606.  Do you have calluses on your heels and, if so, are they cracked? No / don't know Light callus without significant cracking Light callus with cracking Thick callus without significant cracking Thick callus, cracked 607.  Do you have a problem with cracking skin, typically on the fingers, toes or in skin creases? Do not include cracked heel calluses. No / don't know Occasionally / moderate Often / severe 608.  Do you have small bumps on the backs of your arms? No / don't know Yes, some/minor Yes, many/definite 609.  What is your skin color prior to suntan, compared to others of your race, or family members? Significantly lighter/paler A little lighter/paler Average / don't know A little darker/redder Significantly darker/redder 610.  What is your facial coloring prior to suntan, compared to others of your race, or family members? Noticeably pale Slightly pale Average / don't know Slightly dark Noticeably dark, pink, flushed or ruddy 611.  Not counting blushing during embarrassing situations, do you experience facial blushing, flushing or redness more frequently or intensely than would be considered normal? Don't know / I think I'm average No, definitely not Mild / occasionally Moderate / sometimes Major / often 612.  Does your skin seem to have a more yellowish (jaundiced) tone than previously? It may help to look at untanned areas. Don't know No Probably / somewhat Definitely 613.  Skin moistness. Without moisturizer, is your skin...? Very dry A bit dry Average / don't know A bit oily/moist Definitely oily/moist 614.  Is your skin scaly or flaky in areas other than the top of your head (scalp)? Don't know Definitely not Yes, somewhat Yes, significantly 615.  Does your skin tend to itch often, perhaps worse at night? No / don't know Moderately Severely 616.  Do you perspire/sweat...? Very little / not easily Less than average About average / don't know More than average Lots / easily 617.  Do the palms of your hands sweat excessively? No / don't know Moderate problem of less than 1 year Moderate problem of more than 1 year Major problem of less than 1 year Major problem of more than 1 year 618.  Body odor. Does your perspiration (sweat) cause a strong odor? This applies mainly to the armpits and feet. No / don't know Somewhat, but it is manageable Definitely, it is a serious problem for me 619.  Do you bruise easily? No / don't know Mildly Moderately Seriously Severely - I usually have bruises somewhere 620.  Do you have palms and fingertips that are more red than average? No / don't know Somewhat Definitely 621.  Is your skin temperature...? Very cold Colder than average Average / don't know Warmer than average Very warm Add any additional information here for the questions above: Please mention the question number(s) if possible.   SYMPTOMS: SKIN: CONDITIONS 622.  Have you had adolescent acne? No / don't know Yes, moderately / briefly Yes, severely / prolonged 623.  Have you had adult acne? Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 624.  Do you have Telangiectasia (persistent red or blue veins on your face, upper chest or neck)? Don't know No Mild (a few veins) Moderate Severe (many veins) 625.  Have you had Eczema? This includes many kinds of red, blistering, oozing, scaly, brownish, thickened and itching skin conditions, and may be known as dermatitis. Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 626.  Have you had Psoriasis? It is characterized by frequent episodes of redness and itching, and thick, dry, silvery scales in discrete patches on the skin. It is most common on the scalp, trunk, elbows, knees, skin folds and fingernails. Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 627.  Do you have Rosacea (a facial rash usually composed of prominent redness and sometimes also pimple-like bumps that do not become whiteheads or blackheads)? Don't know No, definitely not Mild Moderate Severe 628.  Do you have dandruff (Seborrheic Dermatitis)? No / don't know Some Significant Severe 629.  Actinic keratoses. Small, raised, flaky skin lesions usually found on the forehead in older people. Never had them / don't know Probably have a few Current minor problem Current minor problem, have had many removed Current major problem 630.  Seborrheic keratoses. They have a waxy, pasted-on or stuck-on look. The look is often compared to brown candle wax that was dropped onto the skin. None / don't know I believe I have a few I have some (5-10) I have many (11-30) I have very many (over 30) 631.  Do you have moles that bleed, are enlarging, are painful, or are tender? Don't know No A few / minor problem Several / definitely an issue 632.  Moles. Do you have a lot of dark moles? No / don't know Yes, several Yes, very many 633.  Polyps Never had one / don't know Probably had one/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 634.  Have you had lumps or bumps that sometimes hurt or are tender? Do not include sores, bruises or swollen lymph nodes. Never had one / nothing major / don't know Major episode(s) now resolved Current minor problem Current major problem 635.  Do you tend to get rashes? It is not a problem for me / don't know Generally not, but I do have one now Occasional moderate rashes Frequent moderate rashes / occasional severe Frequent severe rashes 636.  Do you have vitiligo (patches of depigmented/lighter skin)? Never had it / don't know Probably/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 637.  Warts Never had them / don't know Probably/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem 638.  Whether you are male or female, do you have any problems with your nipples, such as itching or a discharge? Don't know No Yes    More questions later... Add any additional information here for the questions above: Please mention the question number(s) if possible.