LIFE STYLE HISTORY
2
LIFE STYLE HISTORY OPT Form 93 V1 (1-2) JAN 06 Clinical Unit: Form Date: - - Month Day Year attach PID label here Patient ID: - - DCC USE R eceived: Date Seq.N o.: Form Coordinator Code: O BSTETRICS & PERIO THERAPY STUDY II For the child's primary caregiver : I have some questions about common habits of yours. 1b. About how many cigarettes do you smoke (or did you, if no longer smoking) per day: cigarettes per day 1. Have you ever smoked cigarettes? Yes 1 No 2 1a. Do you smoke now? Yes 1 No 2 How long ago did you stop smoking? year there any [other] cigarette smokers in the child's household? Yes 1 No 2 Don't know 3 Refused to answer 4 2a. Number who smoke in the house: 3c. In the past 12 months, how many days did you have 5 or more drinks on a single day days 3 Don’t know 4 Refused to answer 3b. On the days you drank alcohol, on the average, how many drinks did you have? drinks 3 Don’t know 4 Refused to answer 3. Have you had an alcoholic beverage in the past 12 months? 2 No 1 Yes 3a. How many days per week in a typical week do you drink any alcoholic beverages (beer, wine, or liquor)? 3 Don’t know 4 Refused to answer days 2 1 Visit:
-
Upload
ashton-rojas -
Category
Documents
-
view
9 -
download
0
description
II. attach PID label here. -. -. Patient ID:. Clinical Unit:. -. -. Month. Day. Year. 4. 1. 2. 1. 3. 2. 1. 2. Yes. Yes. No. No. Refused to answer. Don't know. No. Yes. Form Date:. Coordinator Code:. Visit:. 1. 1. Have you ever smoked cigarettes?. - PowerPoint PPT Presentation
Transcript of LIFE STYLE HISTORY
LIFE STYLE HISTORY
OPT Form 93 V1 (1-2) JAN 06
Clinical Unit:
Form Date: - -Month Day Year
attach PID label here
Patient ID: - -
DCC USE
Received:
Date
Seq. No.:Form
Coordinator Code:
OBSTETRICS & PERIO THERAPY STUDY II
For the child's primary caregiver: I have some questions about common habits of yours.
1b. About how many cigarettes do you smoke (or did you, if no longer smoking) per day: cigarettes per day
1. Have you ever smoked cigarettes?
Yes1
No2
1a. Do you smoke now? Yes1
No2 How long ago did you stop smoking? years
2. Are there any [other] cigarette smokers in the child's household?
Yes1
No2
Don't know3
Refused to answer4
2a. Number who smoke in the house:
3c. In the past 12 months, how many days did you have 5 or more drinks on a single day?
days
3 Don’t know4 Refused to answer
3b. On the days you drank alcohol, on the average, how many drinks did you have?
drinks
3 Don’t know4 Refused to answer
3. Have you had an alcoholic beverage in the past 12 months?
2 No
1 Yes 3a. How many days per week in a typical week do you drink any alcoholic beverages (beer, wine, or liquor)?
3 Don’t know4 Refused to answer
days
21Visit:
OPT Form 93 V1 (2-2) JAN 06
OBSTETRICS & PERIO THERAPY STUDY II Patient ID: - -
The next few questions are about your use of drugs. Remember that your answers are completely confidential.
5. Have you smoked marijuana or hash in the past year?
Yes1
No2
Don't know3
Refused to answer4
Week1
Month25a. How often have you smoked? times per
Weeks ago1
Months ago25b. When did you last smoke?
7. Have you ever used other street or recreational drugs (cocaine, heroin, etc.)?
Yes1
No2
Don't know3
Refused to answer4
Week1
Month27a. How often have you used them? times per
Weeks ago1
Months ago27b. When did you last use them?
4. Are there any [other] people who drink alcoholic beverages (beer, wine, liquor) in the child's household?
Yes1
No2
Don't know3
Refused to answer4
4a. Number who drink alcohol in the house:
6. Are there any [other] people who smoke marijuana or hash in the child's household?
Yes1
No2
Don't know3
Refused to answer4
6a. Number who smoke marijuana or hash in the house:
8. Are there any [other] people who use street or recreational drugs (cocaine, heroin, etc.) in the child's household?
Yes1
No2
Don't know3
Refused to answer4
8a. Number who use street or recreational drugs in the house:
