Demography
Date of assessment
date
Date of Birth
date
Gender
text
White: Origins in the original peoples of Europe, the Middle East, Western Russia, Afghanistan, or the white racial groups of Africa. Black: Origins in any of the black racial groups of Africa. Asian: Origins in the original peoples of the Indian subcontinent, the Far East, Southeast Asia, or the Pacific islands. American Hispanic: Hispanics of North, Central, or South American origin. Other: People whose racial group is not represented above, or whose predominant origin cannot be determined.
text
Smoking History
Smoking behavior
text
Converter for cigars and tobacco: 1 cigar = 7 cigarettes 1 gram (or 0.03 oz.) of tobacco = 1 cigarette
integer
Demography for females
Use the following definitions: Premenarcheal: Females who have not begun to menstruate. Sterile: Premenopausal women who cannot conceive children. (Do not include postmenopausal women in this category.) Postmenopausal: Women who have completed menopause at least one year ago. Potentially able to conceive children: Women of childbearing age who are not sterile.
text
Oral Contraceptive
boolean
Intrauterine contraceptive device
boolean
Sexual Abstinence
boolean
Male Sterilization of Partner
boolean
No contraceptive method
boolean
Double barrier method of contraception consisting of spermicide with either condom or diaphragm.
boolean
Other contraceptive methods
boolean
Details of any contraceptive drugs must be added to the CONCOMITANT MEDICATIONS page.
text
Pregnancy test result
text