Personal and Confidential Information

(Please Print)

What time is it right now? ____________

Date & Day of Week__________________ Code #_________

Sex: 0 = Male 1 = Female Date of Birth ____-____-____

Age__________ Race: 0 - Caucasian

                                    1 - African-American

                                    2 - Hispanic

                                    3 - Native American

                                    4 - Asian

                                    5 - Other___________

1. Have you eaten today? 0 - No 1 - Yes

    If yes, what did you eat & how much?_______________________________

    If yes, what time did you last eat?___________________________________

2. What time did you go to bed last night?_____________

    What time did you get up?____________

    Approximate hours of sleep? ________ hours

3. Do you exercise regularly? 0 - No 1 - Yes

    If yes, what type of exercise do you do? _________________________

    If yes, how often do you exercise each week? _______________

4. Have you exercised vigorously or done any other activity that would raise your heart rate in the last four hours? 0 - No 1 - Yes

    If yes, please describe the activity. _______________________

    If yes, what time did you last do this activity? ______________

5. Do you take any medication regularly? 0 - No 1 - Yes

    If yes, please describe the medication. ______________________________________

    If yes, what time and day was this medicine last taken? _______________________

6. Have you taken any other medication in the last 24 hours? 0 - No 1 - Yes

    If yes, please describe the medication. _____________________________________

    If yes, what time and day was this medication last taken? ________________

7. So far as you know, do you have a fever right now? 0 - No 1 - Yes

8. So far as you know, do you have any of the following medical conditions?

    Heart Condition 0 - No 1 - Yes

    Low blood pressure 0 - No 1 - Yes

    High blood pressure 0 - No 1 - Yes

    Fainting spells or bouts of dizziness 0 - No 1 - Yes

    Diabetes 0 - No 1 - Yes

    Asthma 0 - No 1 - Yes

    Neurological disorders 0 - No 1 - Yes

    Hearing loss or damage 0 - No 1 - Yes

    Other 0 - No 1 - Yes

If yes to any of the above, please describe. _________________________________________

____________________________________________________________________________

9. Do you drink drinks with caffeine, such as coffee, tea, Coke or Pepsi, or other soda with caffeine? 0 - No 1 - Yes

    If yes, how many cups do you drink per day? _________________

    What time and day did you last drink caffeine? ______________

10. Do you smoke, use snuff, or chew tobacco? 0 - No 1 - Yes

    If yes, approximately how many times do you smoke, use snuff, or chew tobacco each day?         _______________

    If yes, what time and day did you last smoke, use snuff, or chew tobacco? ____________

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