your medical history form

[Guest guest]

fill this out at home and keep with you for doctor visits..easy to remember then...theresa

Name _________________________________ Current Date ___________

Please check if you or your family had/has any of the following:

Yourself

Other Family Member

Yourself

Other Family Member

Anemia

[ ]

[ ]

Hardening Arteries

[ ]

[ ]

Ankle Swelling

[ ]

[ ]

Heart Problems

[ ]

[ ]

Arthritis

[ ]

[ ]

Heart Disease

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[ ]

Asthma

[ ]

[ ]

Hepatitis/Yellow Jaundice

[ ]

[ ]

Bladder Trouble/Infections

[ ]

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High Blood Pressure/Hypertension

[ ]

[ ]

Bleeding Tendencies

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[ ]

HIV (AIDS)

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[ ]

Bowel Problems

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[ ]

Kidney Trouble

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Cancer

[ ]

[ ]

Nervous Disorder

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Coughing up Blood

[ ]

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Pneumonia

[ ]

[ ]

Chest Pain

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Shortness of Breath

[ ]

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Depression

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Seizure

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Diabetes

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Sleep Disorder

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Dizziness

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Stroke

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Endocrine

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Skin

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Emphysema

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Blood Clots

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Epilepsy

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Ulcers

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Other __________________________

Other __________________________

Other __________________________

Other __________________________

Please explain any of the above________________________________________________________________________________________________________________________

Have you had a blood transfusion?

[ ]Yes

[ ]No

Did you have a reaction?

[ ]Yes

[ ]No

Are you pregnant?

[ ]Yes

[ ]No

Are you trying to get pregnant?

[ ]Yes

[ ]No

Approximate Height __________________

Approximate Weight __________________

Have you had a recent weight gain?

[ ]Yes

[ ]No

Have you had a recent weight loss?

[ ]Yes

[ ]No

Do smoke or chew tobacco?

[ ]Yes

[ ]No

How much a day? ___________________

Do you drink?

[ ]Alcohol How Much? ____________

[ ]Beer How Often? ____________

(Form provided by Arthritis Insight http://arthritisinsight.com)

Hugs,Theresa