Have you suffered from interstitial cystitis (debilitating chronic pain characterized by urinary urgency, frequency, urination at night and bladder pain)?
Never had it / don't know
Probably, but now resolved
Diagnosed, but now resolved
Current minor problem
Current major problem
554.
Have you had a bladder infection? Symptoms are similar to those of interstitial cystitis except that it is much more common, of shorter duration and generally resolves by itself or with treatment.
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SYMPTOMS: REPRODUCTIVE Some of the questions below are very personal in nature. If you are unwilling to answer a question, skip it by leaving the default "don't know" response. The accuracy of your evaluation will be only slightly affected.
573.
At what age did you become sexually active?
Not applicable / never active
Before age 15
15 to 19
20 to 25
Over 25
574.
What is the approximate number of sexual partners that you have had during your lifetime?
Unwilling to answer / don't know
One or fewer
2 to 5
6 to 20
Over 20
575.
Is your sexual desire (libido)...?
Totally absent
Reduced
Normal / don't know
Increased
Very strong
576.
Frequency of sexual contact with another person.
Under once per month / don't know
Once per week or less
About 2 times per week
3-4 times per week
5 or more times per week
577.
Frequency of any sexual stimulation that results in orgasm.
Under once per month / don't know
Once per week or less
About 2 times per week
3-4 times per week
5 or more times per week
578.
How frequently do you experience premature ejaculation?
Not applicable / don't know
Never / rarely
It was a problem in the past, but not now
Occasionally
Most of the time
579.
Is ejaculation painful?
Don't know
No
Rarely
Sometimes
Often / always
580.
Are you experiencing any symptoms associated with your penis or testicles? Questions about Sexually Transmitted Diseases (STD) will be asked about elsewhere as well as symptoms associated with intercourse / desire.
Don't know
No
Yes, but in the last couple years, not now. More questions later...
Other than AIDS, have you had any form of sexually-transmitted disease (STD)? This includes herpes, chlamydia, HPV, syphills and gonorrhea as examples. Candida is not a STD.
Don't know
No
Yes / probably More questions later...
Enter any additional information here for the questions above:
Please mention the question number(s) if possible.
SYMPTOMS: RESPIRATORY
590.
Do you have a cough that produces mucous?
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
591.
Do you have a cough that does not produce mucous?
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
592.
Do you feel worse when in moldy or musty places?
No / don't know
Somewhat
Very much
593.
Do you sigh frequently, or have 'air hunger' or shortness of breath that is not associated with significant exertion?
Don't know
No
Mildly / occasionally
Moderately / often
Serious sudden unexplained onset
594.
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
595.
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
596.
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
597.
Have you had a problem with laryngitis?
Don't know
No
Yes, but in the past only
Current problem but can talk
Completely lost my voice
598.
Have you been diagnosed with any lung related problems not metioned already? Examples would include asthma, tuberculosis, pneumonia, COPD, acutebronchitis, etc..
Don't know
No
Yes More questions later...
599.
Have you experienced any kind of chest pain, burning, tightness, pressure or discomfort or difficulty breathing within the last year?
Don't know
No
Yes More questions later...
Enter any additional information here for the questions above:
Please mention the question number(s) if possible.
SYMPTOMS: SLEEP
600.
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
601.
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
602.
Do you generally become sleepy after eating?
Rarely / don't know
No
Occasionally
Often
603.
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"
604.
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
605.
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
606.
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 moist
Profusely, sheets are soaked
607.
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
608.
Do you experience bizarre, vivid or nightmarish dreams?
Don't know
Never / rarely
Occasionally
Quite often, quite bad
Often and awful/recurring nightmares
609.
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
610.
Do you have any other sleeping problems? Examples include insomnia, restless legs, snoring, apnea, grogginess and sleep disorders.
Don't know
No
Yes More questions later...
Enter any additional information here for the questions above:
Please mention the question number(s) if possible.
Have you had an enlarged artery called an aneurysm or experienced a ruptured aneurysm? Sometimes cerebral aneurysms are the cause of a 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
614.
Do you have Raynaud's phenomenon (extreme loss of circulation to fingers and/or toes)?
Do you suffer from occasional and unusual pain that may be in your chest, upper left arm or left side of neck?
Don't know
No
Occasionally / moderate
Often / severe
618.
Does your heart sometimes race or palpitate such that you can feel it beating?
No / don't know
Occasionally / moderately
Often / severely
619.
Have you had any kind of heart problem not mentioned above? Examples include heart attack, valve damage, enlargement, weakness, inflammation, failure, pain, etc.
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
628.
Have you ever been diagnosed with Lupus (SLE, Systemic Lupus Erythromatosis)?
Don't know
No, it has been ruled out
Past episodes, now resolved
Current minor problem
Current major problem
629.
Have you ever been diagnosed with Lyme disease?
Don't know
Tests for Lyme were negative
Past episode now resolved
Current minor problem
Current major problem
630.
Do you live in an area where you are exposed to ticks known to carry the bacteria that causes Lyme's disease? Or, have you visited an area where exposure was likely?
Have you been diagnosed with ALS (amyotrophic lateral sclerosis)?
Don't know
No, doctors don't think I have it.
Has been suggested as a possibility
Yes, onset less than 3 years ago
Yes, onset less over 3 years ago
633.
Do you generally have poor wound healing?
No / don't know
Moderate - healing takes longer than it should
Severe - healing takes weeks/months
634.
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
635.
Do you have Sarcoidosis?
Don't know
No
Yes, but now symptom free
Yes, a single organ problem
Yes, a multiple organ problem
636.
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
637.
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
638.
Have you been diagnosed with Sjogrens?
Don't know
No
Past only / It is suspected
Mild / moderate case
Severe case
639.
Have you had inflammation of the thyroid gland - Thyroiditis? This means elevation of antithyroid antibodies like TBII, anti-Tg or anti-TPO (antithyroid peroxidase / antimicrosomal antibody).
Enter any additional information here for the questions above:
Please mention the question number(s) if possible.
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GLOSSARY
Acute: An illness or symptom of sudden onset, which generally has a short duration.
AIDS: Acquired Immune Deficiency Syndrome. An immune system deficiency disorder that suddenly alters the body's ability to defend itself. The AIDS virus invades the T4 helper/inducer lymphocytes and multiplies, causing a breakdown in the body's immune system, eventually leading to overwhelming infection and/or cancer, with ultimate death.
Anemia: A condition resulting from an unusually low number of red blood cells or too little hemoglobin in the red blood cells. The most common type is iron-deficiency anemia in which the red blood cells are reduced in size and number, and hemoglobin levels are low. Clinical symptoms include shortness of breath, lethargy and heart palpitations.
Antibody: A type of serum protein (globulin) synthesized by white blood cells of the lymphoid type in response to an antigenic (foreign substance) stimulus. Antibodies are complex substances formed to neutralize or destroy these antigens in the blood. Antibody activity normally fights infection but can be damaging in allergies and a group of diseases that are called autoimmune diseases.
Asthma: A lung disorder marked by attacks of breathing difficulty, wheezing, coughing, and thick mucus coming from the lungs. The episodes may be triggered by breathing foreign substances (allergens) or pollutants, infection, vigorous exercise, or emotional stress.
Atherosclerosis: Common form of arteriosclerosis associated with the formation of atheromas which are deposits of yellow plaques containing cholesterol, lipids, and lipophages within the intima and inner media of arteries. This results in a narrowing of the arteries, which reduces the blood and oxygen flow to the heart and brain as well as to other parts of the body and can lead to a heart attack, stroke, or loss of function or gangrene of other tissues.
Bacteria: Microscopic germs. Some bacteria are "harmful" and can cause disease, while other "friendly" bacteria protect the body from harmful invading organisms.
Benign: Literally: innocent; not malignant. Often used to refer to cells that are not cancerous.
Bronchitis: Inflammation of the mucous membrane of the bronchial tubes, frequently accompanied by cough, hypersecretion of mucus, and expectoration of sputum. Acute bronchitis is usually caused by an infectious agent and of short duration. Chronic bronchitis, generally the result of smoking, may also be known as Chronic Obstructive Pulmonary Disease (COPD) or Emphysema.
Cancer: Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.
Candidiasis: Infection of the skin or mucous membrane with any species of candida, usually Candida albicans. The infection is usually localized to the skin, nails, mouth, vagina, bronchi, or lungs, but may invade the bloodstream. It is a common inhabitant of the GI tract, only becoming a problem when it multiplies excessively and invades local tissues. Growth is encouraged by a weakened immune system, as in AIDS, or with the prolonged administration of antibiotics. Vaginal symptoms include itching in the genital area, pain when urinating, and a thick odorless vaginal discharge.
Chlamydia: A sexually-transmitted disease that is often without symptoms. Some females experience a white vaginal discharge that resembles cottage cheese, a burning sensation when urinating, itching, and painful intercourse. A clear watery urethral discharge in the male probably is a chlamydia infection.
Chronic: Usually Chronic illness: Illness extending over a long period of time.
Chronic Renal Failure: (CRF) Irreversible, progressive impaired kidney function. The early stage, when the kidneys no longer function properly but do not yet require dialysis, is known as Chronic Renal Insufficiency (CRI). CRI can be difficult to diagnose, as symptoms are not usually apparent until kidney disease has progressed significantly. Common symptoms include a frequent need to urinate and swelling, as well as possible anemia, fatigue, weakness, headaches and loss of appetite. As the disease progresses, other symptoms such as nausea, vomiting, bad breath and itchy skin may develop as toxic metabolites, normally filtered out of the blood by the kidneys, build up to harmful levels. Over time (up to 10 or 20 years), CRF generally progresses from CRI to End-Stage Renal Disease (ESRD, also known as Kidney Failure). Patients with ESRD no longer have kidney function adequate to sustain life and require dialysis or kidney transplantation. Without proper treatment, ESRD is fatal.
Cysts: A closed pocket or pouch of tissue; a cyst may form within any tissue in the body and can be filled with air, fluid, pus, or other material. Cysts within the lung generally are air filled, while cysts involving the lymph system or kidneys are fluid filled. Cysts under the skin are benign, extremely common, movable lumps. These may develop as a result of infection, clogging of sebaceous glands, developmental abnormalities or around foreign bodies.
Cytomegalovirus: (CMV): A member of the herpes virus family which may induce the immune-deficient state or cause active illness, such as pneumonia, in a patient already immune-deficient due to chronic illness, such as cancer or organ transplantation therapy.
Epstein Barr virus: (EBV): A virus that causes infectious mononucleosis and that is possibly capable of causing other diseases in immunocompromised hosts.
Gonorrhea: A sexually-transmitted disease that is often without symptoms. If there are symptoms in the female, they include frequent and painful urination, cloudy vaginal discharge, vaginal itching, inflammation of the pelvic area, and abnormal uterine bleeding. If the male has a purulent (pus-like) urethral discharge, he should assume he has gonorrhea until proven otherwise.
HIV: Abbreviation for human immunodeficiency virus, a retrovirus associated with onset of advanced immunodeficiency syndrome (AIDS).
Immune System: A complex that protects the body from disease organisms and other foreign bodies. The system includes the humoral immune response and the cell-mediated response. The immune system also protects the body from invasion by making local barriers and inflammation.
Interstitial Cystitis: A chronic bladder problem involving a bladder wall that is inflamed and irritated. Symptoms include an urgent need to urinate, both daytime and nig
More questions later...