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TZ-SHR-103318
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2013.07.30
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54 page / 455.5 KB
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national screening program   regular checkup life cycle-based checkup  
¡Ø answers must be provided for all questions so the information will be reported correctly.
fist name  
residential id no.
tel.no.
home  given name  cell phone   health insurance medicaid recipient  e-mail address  current address  post code  
-
¡Ø do you agree to receive health information or notices from the nhic (national health insurance corporation), kcdc (korea centers for disease control and prevention), ncc(national center for cancer), and/or health centers by letters or e-mail? (please check )
¡Ø these are questions about your medical history.
¡Ø please complete the following questions about your present condition by ticking the appropriate box.
1.have you ever been diagnosed by a medical doctor with any of the following diseases (box a) or are you currently taking any medication (box b)?
brain stroke/paralysis  heart disease  (heart attack)  high blood pressure  diabetes  dyslipi demia  tuberculosis  other   (cancer)  a  b  
2.has anyone in your family died from or gotten the any following diseases?
name  brain stroke/paralysis  heart disease  (heart attack)  high blood pressure  diabetes  other (cancer)  yes  
3.are you a hepatitis b virus antigen carrier ? ¨ç yes ¨è no ¨é no idea
¡Ø these are questions about smoking.
4.please complete the following questions about your present condition by ticking the appropriate box
xxx-xxx.have you ever smoked over 5 packs of tobacco (100 cigarettes) in your life ?
¨ç no, i never smoked.(¢Ñ go to the question 5) ¨è yes, i used to smoke but quit (¢Ñ go to the question xxx-xxx)
¨é yes, im still smoking (¢Ñ go to the question xxx-xxx)
xxx-xxx.if you used to smoke but you are not smoking now, please answer the following.
for how many years had you smoked?
total years  
how many cigarettes in a typical day did you smoke before you quit?
cigarettes  
xxx-xxx.if you are still smoking, please answer the following.
how long have you been smoking ?
total years  
how many cigarettes on average do you smoke in a typical day?
cigarettes     (ÀÌÇÏ »ý·«)