|
| 1. General information |
| 1. Region |
| 2. Date of screening |
| 3. Full name |
| 4. Age |
| 5. Nationality |
| 6. Gender: M-F |
| 7. Monthly income per 1 family member |
| 8. Home address |
| 9. Education: without education, primary, secondary, secondary special, higher |
| 10. Occupation |
| 11. Place of work |
| 12. Position |
| 13. Harmful factors at work: vibration, dust, cooling, physical exertion, etc. |
| 14. Disability from childhood what disease |
| 15. Disabled (which groups 1, 2, 3) what disease |
| 16. Determination date of disability |
| 17. How long did you live in this place (years) |
| 18. Marital status: married, single, widow |
| 19. Smokes: no, yes (<10, >10 cigarettes per day) |
| 20. Consumes alcohol: no, yes, how many: <0.5 liters per week, >0.5 liters per week wine, vodka, beer |
|
| II. Anamnesis |
| Diseases: |
| 1. Measles, mumps, chickenpox, scarlet fever, whooping cough, dysentery, etc. |
| 2. Congenital malformations |
| 3. Травмы (Жарақаттар)-yes, no |
| 4. Seizures with loss of consciousness-yes, no |
| 5. Operations to |
| 6. Venereal diseases, (detection year) |
| 7. Dizziness constantly, often, rarely, no |
| 8. Noise in head constantly, often, rarely, no |
| 9. Heartache constantly, often, rarely, no |
| 10. Dyspnea, suffocation constantly, often, rarely, no |
| 11. Accelerated heartbeat constantly, often, rarely, no |
| 12. Heart failure constantly, often, rarely, no |
| 13 Legs swelling constantly, often, rarely, no |
| 14. Jaundice (detection year) |
|
| 1. Pulmonological profile |
| 1. Detected lung tuberculosis (detection year) |
| 2. Dispensary observation for non-tuberculosis lung diseases-yes, no |
| 3. Attacks of suffocation-yes, no |
| 4. Cough: persistent, frequent, rare. |
| 5. Frequent bronchitis, pneumonia-yes, no |
| 6. Colds with cough, runny nose currently-yes, no |
| 7. Cough more than 2 months a year.-yes, no |
| 8. Sputum secretion: constantly, often, rarely, no |
| 9. Feeling of wheezing in the chest: constantly, often, rarely, no |
| 10. Chest pain: constantly, often, rarely, no |
| 11. Dyspnea, shortness of breath: constantly, often, rarely, no |
| 12. Elevated temperature: constantly, often, rarely, no |
| 13. Frequent colds: 3–5 times a year, more than 5 times. |
| 14. Allergy-yes, no |
| 15. Operated because of lung diseases-yes, no |
|
| 2. Cardio rheumatology profile |
| 1. Dispensary observation: for rheumatism, chorea, coronary heart disease, hypertension, etc. -yes, no |
| 2. Had a rheumatism, chorea, coronary heart disease, hypertension, etc., without dispensary observation-yes, no |
| 3. Detected heart defect, a heart murmur-yes, no |
| 4. Joint pain with redness, swelling-yes, no |
| 5. High blood pressure constantly, often, rarely, no |
| 6. Low blood pressure constantly, often, rarely, no |
| 7. Headache constantly, often, rarely, no |
|
| 3. Nephrological profile |
| 1. Dispensary observation of genitourinary system diseases-yes, no |
| 2. Genitourinary system diseases without dispensary observation-yes, no |
| 3. Renal colic-yes, no |
| 4. Urine with blood-yes, no |
| 5. Abnormalities in urine tests-yes, no |
| 6. Painful, difficult urination constantly, often, rarely, no |
| 7. Cloudy urine constantly, often, rarely, no |
| 8. Operated due to kidney and urinary tract disease-yes, no |
| 9. Urinary incontinence-yes, no |
|
| 4. Gastroenterological profile |
| 1 Observation about hepatitis, pancreatitis, peptic ulcer, other digestive diseases-yes, no |
| 2 Jaundice-no, 1 time, more than 1 time |
| 3. Found stomach ulcer, duodenal ulcer-yes, no |
| 4. Gallstones-yes, no |
| 5. Polyp of the stomach, intestines-yes, no |
| 6. Found worms, giardia-yes, no |
| 7. Increased acidity of gastric juice-yes, no |
| 8. Pain “in the pit of the stomach” constantly, often, rarely, no |
| 9. Pain in the right hypochondrium constantly, often, rarely, no |
| 10. Pains all over the abdomen constantly, often, rarely, no |
| 11. Abdominal pain to empty stomach at night constantly, often, rarely, no |
| 12. Abdominal pain after eating fatty, fried, spicy food constantly, often, rarely, no |
| 13. Seasonality of pain (spring, autumn) constantly, often, rarely, no |
|
| 5. Hematological profile |
| 1. Dispensary observation about blood diseases-yes, no |
| 2. Decreased hemoglobin, anemia in past-yes, no |
| 3. Bleeding (nasal, hemorrhoidal, other) often, rarely, no |
| 4. Copious menstrual blood loss-yes, no |
| 5. Frequent “bruises,” hemorrhages on the skin-yes, no |
| 6. Found abnormalities in blood tests before constantly, often, rarely, no |
| 7. General weakness constantly, often, rarely, no |
| 8. Admixture of blood in feces-yes, no |
|
| 6. Endocrinological profile |
| 1. Diagnosed with diabetes mellitus, obesity, thyrotoxicosis-yes, no |
| 2. Other diseases of the endocrine system-yes, no |
| 3. Previously registered an increased sugar in the blood, sugar in the urine-yes, no |
| 4. Loosening, loss of teeth-yes, no |
| 5. Furunculosis, frequent pustular skin diseases-yes, no |
| 6. Thirst constantly, often, rarely, no |
| 7. Weight loss by 4-5 kg over the last year-yes, no |
| 8. Thyroid surgery-yes, no |
|
| 7. Gynecological profile |
| 1. Pregnancy (how many) |
| 2. Childbirth (how many) |
| 3. Protected-yes, no |
| 4. Was she ill with colpitis, metritis, endocervicitis, inflammation of the uterine appendages-yes, no |
| 5. Uterine tumors-yes, no |
| 6. Ovarian tumors-yes, no |
| 7. Menstrual cycle determined: immediately; after several menstruations; not determined |
| 8. Painful menstruation-yes, no |
| 9. Undergone surgery on the genitals (removal of the uterus, appendages, cesarean section, ectopic pregnancy, etc.)–yes, no |
|
| 8. Nervous diseases |
| 1. Dispensary observation by a neurologist: no; yes |
| 2. Complaints of headache: no; dull diffusion, paroxysmal. |
| 3. Headache rarely, periodically, constantly |
| 4. Headache is accompanied by nausea, vomiting-yes, no |
| 5. Loss of consciousness-yes, no |
| 6. Convulsions Судороги: no; generalized; local; small; febrile |
| 7. Dizziness-yes, no |
| 8. Nystagmus-yes, no |
| 9. Muscle strength: preserved; reduced |
| 10. Sensitivity: reserved, broken superficially; deeply |
| 11. Sleep: not disturbed; disturbed |
| 12. Speech is impaired: no; stuttering; dysarthria (violation of the pronunciation side of speech); aphasia (loss of the ability to use words and phrases as a means of expressing thoughts). |
| 13. Memory impairment: none; reduced. |
| 14. Memory decline expressed, unexpressed, none |
|
| 9. Additional information |
| 1. Irritable, calm |
| 2. The ability to have sexual relations-preserved, reduced, lost |
| 3. The ability to work-preserved, reduced, lost |
| 4. Fatigue-yes, no |
| 5. Insomnia-yes, no |
| 10. Self-assessment of condition |
| Assessment on a five-point system |
| 1 2 3 4 5 |
The survey was conducted by ______________________________________
Position, Full name, date |
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