Please provide the following contact information:

Name
Street Address
Mailing Address (if different)
City
State/Province
Zip/Postal code
Home Phone
E-mail

Please identify and describe yourself:

Date of birth
Sex	Male Female
Height
Weight
UCLA ID #

Work Phone
FAX

Have you had a family history of any of the following diseases? (check all that apply)

Colon Cancer (if yes, specify below; e.g. family member, type of problem)
Cardiac Disease (if yes, specify below)
Diabetes
High Blood Pressure
Prostate Cancer
Arthritis (such as Lupus or Rheumatoid Arthritis)
Other (specify below)
Breast Cancer (for women only; if yes, specify treatment below)   
Osteoporosis (for women only; if yes, specify treatment below)

Specifics of diseases or treatments:
         

Enter the date of last treadmill test.
          -- Results were:

Enter the date of last Flexible Sigmoidoscopy.
          -- Results were:

Enter the date of last chest X-ray.
          -- Results were:

Enter the date of last eye examination.
          -- Results were:

Enter the date of last Mammography. (for women only)
          -- Results were:

Enter the date of last Pap Smear. (for women only)
          -- Results were:

Do you currently or have you ever smoked
          Yes No

If yes, on average, how many cigarettes do you currently smoke per day?
         
 

Describe your smoking history (include number of years as a smoker, quantity smoked per day)
         
 

Have you ever had surgery?
          Yes No

If yes, please specify condition and date(s) of surgery.
          

Are you currently being treated for any type of health problem?
           Yes No

If yes, please specify condition, treatment program, and prescribed medications.
          

Within the last 6 months, have you experienced any type of chest pain?
           Yes No

Please describe any particular health concerns or symptoms you are currently experiencing.