Past and Current Illnesses - National Institutes of Health



Condition/IllnessYesNoDon’tKnowAge atOnsetStill Present?Blood disordersAnemia requiring treatment or blood transfusionsMononucleosisThrombocytopenia (low platelets)Other bleeding disorder Specify:Blood clot disorder (clots in legs, lungs) Specify:Sickle cell traitSickle cell diseaseMalariaOther blood disorders Specify:Cardiovascular Irregular heart beat or palpitations Heart attack, coronary artery disease, angina, bypass surgery, stent, other Specify:Heart failureHeart murmurMalfunctioning heart valvesHigh blood pressure (hypertension)Very low blood pressureOrthostatic intolerance or POTSHigh total or LDL (“bad”) cholesterol or triglycerides Specify:Cardiomyopathy, myocarditisPeripheral arterial diseaseHeart rhythm problem: atrial fibrillation, pacemaker Specify:Other cardiovascular conditions Specify:ChestAsthmaChronic bronchitis, emphysema (COPD)Pneumonia (bacteria, virus) Specify type:TuberculosisOther chronic lung condition Specify:Condition/IllnessYesNoDon’tKnowAge atOnsetStill Present?Ear/Nose/Throat conditions Frequent sinus infections Nasal allergies/rhinitisNasal polypsHearing lossTinnitus (ringing or sounds in the ears)Frequent throat infection (pharyngitis) Frequent ear infections Bleeding gums (gingivitis) Recurrent infections of tonsilsEye conditionsCataractsGlaucomaOptic neuritisOther eye condition Specify:Endocrine and metabolicUnderactive thyroid (hypothyroidism)Overactive thyroid (hyperthyroidism)Thyroid nodules or cancerDiabetes (type 1 or 2)Hypoglycemia (low blood sugar)Metabolic syndromeOverweight/obesityUnderactive adrenal (Addison disease)Overactive adrenal (Cushing disease)Pituitary gland disorderGastrointestinalHeartburn or reflux (GERD)GastritisStomach or duodenal ulcerEnteritisColitisCrohn’s diseaseUlcerative colitisIrritable bowel syndromeMalabsorptionCeliac disease (celiac sprue)ConstipationPancreatitisGallstones or gallbladder infectionLiver cirrhosisHepatitis (types A, B or C)Other liver disease (Specify: )NeurologicalMigraine headachesFaintingLoss of consciousness (not fainting)Meningitis or encephalitisPeripheral neuropathyMultiple sclerosisSeizures, convulsions, epilepsy, pseudoseizuresStroke or TIA (mini-stroke)Alzheimer’s or other dementia Specify:NarcolepsySleep apneaRestless legs syndromeOther sleep disorder Specify:Neuromuscular disorders: (e.g., Huntington’s, amyotrophic lateral sclerosis, muscular dystrophy, myasthenia gravis Specify:Guillain-Barré syndromeParkinson’s diseaseTraumatic brain injury/concussionMuscle disease Specify:RheumatologicalOsteoarthritisRheumatoid arthritisFibromyalgia or myofascial pain syndromeNeck arthritis/disc diseaseSpine arthritis/disc diseaseSystemic lupus erythematosusMultiple broken bones in the pastPolymyalgia rheumatica/temporal arteritisGoutLyme diseaseRheumatic feverSjogren’s syndromeSarcoidosisEhlers-Danlos syndromeTemporo-mandibular joint syndromeOther autoimmune disease Specify: PsychologicalAnxietyDepressionAnorexia or bulimiaDrug abuseAlcohol abuse/dependencyObsessive-compulsive disorderAttention deficit disorder (ADD or ADHD)Manic depressive or bipolar disorderPTSDOther type of psychosisSkin problemsHivesContact dermatitisEczemaPsoriasisMastocytosisOther skin problems Specify:Tumors/CancerLung cancerBreast cancerProstate cancerColorectal cancerBladder cancerNon-melanoma skin cancerMelanomaLymphomaLeukemiaKidney cancerOther cancer(s) Specify:Urogenital conditionsGenital herpesOther sexually transmitted diseases Specify:Interstitial cystitisUrinary tract infectionsKidney or bladder stonesKidney failureOther kidney problem Specify:Female conditions onlyHeavy/excessive menstrual bleedingIrregular periodsBleeding between periodsMissing periods (other than pregnancy)EndometriosisPelvic inflammatory diseasePremenstrual syndromeNumber of pregnancies (how many: )Number of live births (how many: )Number of abortions (how many: )Number of miscarriages (how many: )InfertilityPolycystic ovary syndrome (PCOS)Vaginal yeast infectionsOther genital infections Specify:Other gynecological conditions Specify:Male condition onlyEpididymitisProstate enlargement or prostatitisVaricoceleImpotenceSexually transmitted diseases Specify:Other male problems Specify:MiscellaneousHIV infectionImmune deficiency (other than HIV) Specify: AnaphylaxisOral herpes (cold sores)Multiple chemical sensitivitiesEnvironmental hypersensitivityOther sleep disorder Specify:Organ transplant Specify organ:Past SurgeryType of SurgeryYesNoInstitution/City SurgeryPerformedYear(s) ofSurgeryKnee arthroplastyCoronary angioplasty/stentExcision of disc in the spineFusion of spine bones (vertebrae)Hip replacementGall bladder removalType of SurgeryYesNoInstitution/City SurgeryPerformedYear(s) ofSurgeryColon removal (partial or total)HysterectomyOvaries removedTubes tiedVasectomy (men)Circumcision (men)Removal of adhesions in abdomenFracture of hip, thigh, lower leg bonesCoronary artery bypass graft (CABG)Organ transplant Specify organ:List Other Surgeries: ................
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