Medical Illnesses or Conditions (list any chronic conditions which you have been diagnosed to have)
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Have you ever had or been diagnosed to have: (please check any/all that apply)
Cataracts
Glaucoma
Asthma
Allergies
Stroke
Seizures/Epilepsy
Heart Attack or Angina
Heart Disease
Heart Murmur
High Blood Pressure
Pneumonia
TB/Lung Disease
Pleurisy
Jaundice or Liver Disease
Ulcers
Digestive Disorder
Hemorrhoids
Kidney Disease
Kidney Stones
Diabetes or Pre Diabetes
Thyroid Disease
Operations:
Anemia
Bleeding Disorders
Bone or Joint Disease
German Measles
Rheumatic Fever
Chicken Pox
Syphilis
Depression
Frequent Infection
Cancer
High Cholesterol
Prostate Enlargement
Please list any surgeries and the approximate year
Year
Surgery
Hospitalizations:
Other than operations
Year
Reason
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Family Medical
History
Age
Health (list significant illness)
Age at
Death
Hospital
If deceased, cause of death?
Comments
Father
Mother
Brothers or Sisters
Spouse
Children
Has any blood relative ever had? (Check if Yes and indicate the relationship to yourself)
_____ Alzheimer’s ___________________ _____ Heart Attack before age 55 _____________________
_____ Alcoholism __________________
_____Tuberculosis ___________________ _____ Bleeding Disease _____________________________
_____ Mental Disorder_______________
_____Diabetes ______________________ _____ Stroke ______________________________________ _____ Allergies _____________________
_____High Blood Pressure_____________ _____ Seizures ____________________________________
_____ Asthma ______________________
_____Heart Disease__________________ _____ Depression/Suicide____________________________
_____ Cancer ______________________
Immunizations (check if Yes and indicate the year of your last injection)
____Influenza_________
___Pneumonia__________
___MMR__________ ___Tetanus_________
___Hepatitis A or B_________ __Other_____
Transfusions: Have you ever had a blood or plasma transfusion? Please circle Yes or No
Females only Are you pregnant, planning a pregnancy or currently nursing a child? Yes or No If yes, which _________________
Date of last Menstrual period?____________
[SunMed Primary Care 2015]
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