General Survey Module F: Medical History Now I’m going to ask you a few questions about illnesses you may have had and the kinds of medicines you may have used. Prior to the incident, have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Medical Condition Yes (Please specify) ______________________ No Allergies? Unsure Yes No Asthma? Unsure Yes No Diabetes? Unsure Yes No High blood pressure? Unsure Yes Chronic obstructive pulmonary disease No (COPD) or emphysema? Unsure Yes No Heart Disease? Unsure Yes (Please specify)_______________________ No Physical disability that hinders mobility? Unsure Yes (Please specify) ______________________ Psychological condition such as anxiety, No depression or dependence disorder? Unsure Yes (Please specify) _____________________ No Cancer? Unsure Yes Immune disorders such as lupus, No rheumatoid arthritis, or HIV? Unsure Yes Neurological conditions such as No Parkinson’s disease or multiple sclerosis? Unsure
General Survey Module F: Medical History Now I’m going to ask you a few questions about illnesses you may have had and the kinds of medicines you may have used. Prior to the incident, have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Medical Condition Allergies? Yes (Please specify) ______________________ No Unsure Asthma? Yes No Unsure Diabetes? Yes No Unsure High blood pressure? Yes No Unsure Chronic obstructive pulmonary disease (COPD) or emphysema? Yes No Unsure Heart Disease? Yes No Unsure Physical disability that hinders mobility? Yes (Please specify)_______________________ No Unsure Psychological condition such as anxiety, depression or dependence disorder? Yes (Please specify) ______________________ No Unsure Cancer? Yes (Please specify) _____________________ No Unsure Immune disorders such as lupus, rheumatoid arthritis, or HIV? Yes No Unsure Neurological conditions such as Parkinson’s disease or multiple sclerosis? Yes No Unsure
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