STANDARD HEALTH QUESTIONNAIRE FOR ... - wship

Section K. Other ConditionsHave you been diagnosed, treated, medicated, and/or monitored for any of the conditionslisted in the table below within the time frame specified? Only answer YES if a doctor or otherlicensed medical provider told you that you have or had this condition.○ Yes○ NoIf YES, fill in the circle next to the condition you have (or had) only if the applicable time frame applies toyou.If NO, continue on to the next section.Section K. Other Conditions:Fill in the circle for eachFor which conditions have you been diagnosed, treated, medicated, condition you have (or had)and/or monitored? In the last 12months?In the last 5years?201Adverse environmental exposures (examples: angioedema, food allergies, heatstroke, electrocution – mark any burns from the electrocution separately)○Chromosomal anomalies (examples: autosomal deletions, Cri du Chat202syndrome, Down’s syndrome, Edwards' syndrome, Klinefelter's syndrome,Patau's syndrome, Prader-Willi syndrome, Turner's syndrome, Velo Cardio○Facial syndrome (VCFS)) NOT Fragile X syndrome203 Eye – cataract ○Eye – internal infection (examples: chorioretinitis, endophthalmitis, pars204planitis, viral infections of the inner eye, vitreous abscess)○205 Eye – glaucoma or other intra-occular hypertension ○206 Eye – macular degeneration ○207 Eye – retinopathy (example: diabetic retinopathy) ○Immunodeficiencies – deficiency of humoral immunity (examples: common208variable immunodeficiency, hypogammaglobulinemia)○209 Immunodeficiencies – other (example: Wiskott-Aldrich syndrome) ○210 Mental retardation ○Poisonings and toxic effects of drugs (examples: all drug reactions, venomous211bites)○212 Septicemia with septic shock ○213Sexually transmitted diseases disseminated to other parts of the body(examples: chlamydia outside the genitals, Reiter's disease)Sinusitis – chronic (examples: more than 3 sinus infections in past 12 months,214allergic sinus reactions, hay fever, chronic rhinitis)215 Tuberculosis – pulmonary ○216Tuberculosis – disseminated (tuberculosis spread to other organs beyond thelungs)Other ear, nose, and throat conditions (examples: acute sinusitis, cochlear217implants, ear infections, hearing disorders, hearing loss, nasal congestion iftreated by a physician, sleep apnea, sore throat if treated by a physician,○tinnitus, tonsillitis)TABLE CONTINUED ON NEXT PAGE○○○Washington State Health Insurance Pool 23 10-01-09 (Page 2 Revised 042110 per SBH 2841)