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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