MEDICAL HISTORY
MEDICAL HISTORY
|Condition |YES |NO |Description (if |Start Year of |Still Present? |If still present, is |
| | | |needed) |Diagnosis or |(circle one) |medication required? |
| | | | |Condition | | |
|Seasonal Allergies | | | | |Yes or No |Yes or No |
|Drug Allergies (Please List) | | | | |Yes or No |Yes or No |
| Other allergies? | | | | |Yes or No |Yes or No |
|HEENT Disorders | | | | | | |
| History of HA’s | | | | |Yes or No |Yes or No |
| Other | | | | |Yes or No |Yes or No |
|Cardiovascular | | | | | | |
| HTN | | | | |Yes or No |Yes or No |
| CAD | | | | |Yes or No |Yes or No |
| Stroke | | | | |Yes or No |Yes or No |
| Other | | | | |Yes or No |Yes or No |
|Respiratory | | | | | | |
| Asthma | | | | |Yes or No |Yes or No |
| TB | | | | |Yes or No |Yes or No |
| Pneumonia | | | | |Yes or No |Yes or No |
| Chronic Pulmonary Disease | | | | |Yes or No |Yes or No |
| Other | | | | |Yes or No |Yes or No |
|Endocrine & Metabolic | | | | | | |
| Diabetes Mellitus | | | | |Yes or No |Yes or No |
| Thyroid Disorder | | | | |Yes or No |Yes or No |
| Pancreatic disorder | | | | |Yes or No |Yes or No |
| Other | | | | |Yes or No |Yes or No |
|Immune System | | | | | | |
| AIDS | | | | |Yes or No |Yes or No |
| Collagen Vascular | | | | |Yes or No |Yes or No |
|Disease | | | | | | |
| Other | | | | |Yes or No |Yes or No |
|Hematology & Lymphatic | | | | | | |
| Thrombocytopenia | | | | |Yes or No |Yes or No |
| Anemia | | | | |Yes or No |Yes or No |
| Cancer | | | | |Yes or No |Yes or No |
| Lymphoma | | | | |Yes or No |Yes or No |
| Other | | | | |Yes or No |Yes or No |
|Dermatological | | | | | | |
| Rashes | | | | |Yes or No |Yes or No |
| Lesions | | | | |Yes or No |Yes or No |
|Musculoskeletal | | | | | | |
| Pain | | | | |Yes or No |Yes or No |
| Arthritis | | | | |Yes or No |Yes or No |
| Weakness | | | | |Yes or No |Yes or No |
| Other | | | | |Yes or No |Yes or No |
|Gastrointestinal/Digestive | | | | | | |
| GERD | | | | |Yes or No |Yes or No |
| Hepatitis A, B or C | | | | |Yes or No |Yes or No |
| Peptic Ulcer Disease | | | | |Yes or No |Yes or No |
| Other | | | | |Yes or No |Yes or No |
|Genitourinary | | | | | | |
| Kidney stones | | | | |Yes or No |Yes or No |
| Renal Insuffiency | | | | |Yes or No |Yes or No |
|Condition |YES |NO |Description |Start Year of |Still Present? |If still present, is |
| | | | |Diagnosis or |(circle one) |medication required? |
| | | | |Condition | | |
| Prostate disorder | | | | |Yes or No |Yes or No |
| Other | | | | |Yes or No |Yes or No |
|Neurologic/ Psychiatric | | | | | | |
| Depression | | | | |Yes or No |Yes or No |
| Anxiety | | | | |Yes or No |Yes or No |
| Seizures | | | | |Yes or No |Yes or No |
| Other neurologic | | | | |Yes or No |Yes or No |
|Procedures/surgical history | | | | | | |
| | | | | |Yes or No |Yes or No |
| | | | | |Yes or No |Yes or No |
| | | | | |Yes or No |Yes or No |
|Other Medical History | | | | | | |
| | | | | |Yes or No |Yes or No |
| | | | | |Yes or No |Yes or No |
| | | | | |Yes or No |Yes or No |
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