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Patient Name: Never Former Current
ID: No
Patient Characteristics: Social Yes
Age:
Gender:
Height:
Weight:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Waist Circumference:
Hip Circumference:
Race:

Tobacco:

Alcohol:

Medical History:

Surgical History:

Medications:

Review of Systems: NO YES
NO YES
Skin Disorder
Endocrine disorder such as thyroid, adrenal, hypothalamic
Diabetes
Pulmonary disorder
Myocardial infarction
Stroke
Peripheral vascular disease
Hypertension
Hyperlipidemia
Heart failure
Arrhythmia
Gastrointestinal disorder
Liver disease
Kidney disease
Neurologic disorder
Musculoskeletal disorder
Chronic inflammatory disorders such as rheumatic disease
Chronic infectious disorders such as HIV, Hepatitis, TB
Frequent infections
Infection in the last 3 months requiring antibiotics
Hematologic disorder
Malignancy in the past 5 years

Eligible for Study?