Black Hills Health and Education Center

Follow-up Questionnaire

Please fill out all fields that have a red asterisk and any others that apply to you.

First Name*
Last Name*
Date attended BHHEC*
Same address as when you attended BHHEC?*
If you reside at a different address, please fill out the following:
Current telephone no.
Email*
Address 1
City
State or Province
Zip or Postal Code
Country
Health Information
How many prescription medications do you take?*
List current prescription meds you are taking:*
Do you Smoke?*	yes no
Have you ever smoked?*	yes no
If yes, how many years since you quit?
Are you Diabetic?*	yes no
If yes, what type?	Type I Type II
List any surgeries or medical problems since last report:*
Number of hospitalizations since last report*
Number of ER visits since last report*
Most frequent hospital diagnosis:
Most frequent ER diagnosis:
Level of general pain you feel regularly: (1-10)*
Where is pain located?*
Frequency of current symptons*	No Symptoms Once a week or so Twice a week or so Three times a week or so Four times a week or so Five times a week or so Six times a week or so Daily
Do you suffer from chronic cough?*	yes no
Do you suffer from Asthma?*	yes no
Do you suffer from Angina pain?*	Never With maximum exertion With moderate exertion With minimum exertion Always, even at rest
Do you experience shortness of breath?*	Never With maximum exertion With moderate exertion With minimum exertion Always, even at rest
Your state of well being:*	Not well at all Poorly most of the time Have good and bad days Mostly well Always or almost always well
Your energy level:*	No energy ever Rarely energetic Energetic about half the time Usually energetic Always full of energy and rarely lack it
Have you continued on the BHHEC program?*	Not at all 25% 50% 75% 100%
Hours of sleep each night (average)*
Glasses of water daily (average)*
General Exercise*	Don't exercise at all Exercise 1/2 hour 2-3 times per week Exercise 1/2 hour 3-5 times per week Exercise 1 hour 3-5 times per week Exercise more than 1 hour 5 times per week
Number of minutes of resistance exercise weekly (average) (with weights or other forms of resistance)*
Number of miles you walk daily (average)*
Usual Diet*	Vegan - no meat or animal products Lacto-ovo vegetarian - milk and egg products Occasional meat - mainly vegetarian Fish and/or chicken regularly but no red meat Full meat and potatoes
Spiritual Status:*	Atheist, do not believe in God at all Believe in a higher power, not necessarily a personal God Believe in a personal God, do not fellowhip with like believers regularly believe in personal God, regularly fellowship with like believers, but not satisfied with present religious experience Most committed, student of the Bible with growing relationship to God
Beck Depression Inventory score (if applicable)
Current height in inches:*
Current weight in lbs:*
Current waist measurement in inches*
Current hip measurement in inches*
Blood pressure*
Resting Pulse*
Have you had a Bone mineral density test done since your last report?*	yes no
If so, what was the BMD measurement?
Are you depressed?*	yes no
Do you have migraine headaches?*	yes no
Latest lab report:*	Not sent Faxed Mailed
Type of latest lab report*
Has your BHHEC experience continued to be a help to you?*	yes no
How has it continued to help you?
Share successes or failures, or any other comments