Medical History (Confidential)

    Medical History form


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    EMERGENCY CONTACT INFORMATION


    MAJOR COMPLAINT

    How did your symptoms develop:


    Is there a pattern to when your symptoms occur?

    FAMILY HISTORY

    Check all which have occurred in any of your blood relatives:AlcoholismAllergyBleed easilyCancerDeathDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessObesityStroke

    PERSONAL HISTORY


    Check illnesses or conditions you have or had in the past:AIDs/HIVAlcoholismAllergiesAntibiotic useAsthmaBleed easilyCancerChicken PoxDiabetesEpilepsyGallbladder ProblemsGlaucomaHeart DiseaseHepatitisHigh Blood PressureHigh FeversJaundiceKidney ProblemsMeaslesMeningitisMental DisordersMultiple SclerosisMumpsPacemakerPneumoniaPolioRheumatic FeverScarlet FeverStrokeThyroid DisordersTuberculosisTyphoid FeverUlcersVascular DiseaseVenereal Disease