TTU Vascular health lab - patient information

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Please answer the following questions.

Name *

Email *

Phone number *

What is your age? *

What is your height? (inch.) *

What is your weight? (lbs.) *

Are you post-menopausal?

Yes

Clear selection

If so, for how long (years and months)?

Was it natural or surgical (uterus removal) menopause?

Have you been on hormone replacement therapy within the last 6 months?

Yes

Clear selection

If so, what kind of hormone replacement therapy? Please specify the type, dose, and duration of hormone replacement therapy.

Have you been diagnosed with type II diabetes? *

Yes

Have you been diagnosed with high blood pressure? *

Yes

If diagnosed with high blood pressure, for how long?

Are you taking any meds to help control your blood pressure

Yes

Clear selection

If so, what kind of medication are you taking? Please specify type, dose and duration of blood pressure medication.

Have you been diagnosed with leg peripheral artery disease, bad circulation? *

Yes

Have you been diagnosed with heart disease? *

Yes

Have you been diagnosed with glaucoma or herpes simplex? *

Herpes simplex

Glaucoma

None of the above

Have you been diagnosed with asthma? *

Yes

Have you been diagnosed with any endocrine disorders? *

Yes

Have you been diagnosed with any cognitive (mental) deficits? *

Yes

If diagnosed with cognitive (mental) deficits, please specify?

Please indicate any additional medication(s) you may be taking. Please specify type, dose and duration of medication(s). If you are not taking any, please say none. *

What types of vitamins or sport supplements (e.g. hormones, amino acids, creatine) are you taking? Please be as specific as possible. *

Are you currently involved in a structured exercise program? *

Yes

When was the last time that you participated in a structured exercise program? *

Do you regularly do aerobic exercise? *

Yes

Is it more than 30 minutes daily for more than 3 days per week?

Yes

Clear selection

Do you regularly do resistance exercise? *

Yes

Are you a smoker? *

Yes

Have you been smoking more than 20 cigarettes per day within the last year? *

Yes

Do you have any joint implants, knee osteoarthritis, recent thrombosis, recent operative wounds, intense migraines, tumors, and hernias? *

Do you have any other health concerns/previous diagnosis that have not been listed in this health questionnaire that we should know about? *

Please identify your ethnicity. *

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