Illinois Health Record
Name:
Club:
YOUR FAMILY’S HEALTH HISTORY
Parents
Name
Birthdate
Birthplace
Nationality
Occupation
Height at age 25
Weight at age 25
Weight now
General Physical
Condition
Father:
Mother:
Year:
YOUR OWN HEALTH HISTORY
Diseases
Diphtheria
Measles
Mumps
Pnuemonia
Scarlet Fever
Strep sore throat
Whooping cough
Polio
Rhuematic fever
Heart disease
Other
Age Nature and Effect
Major Diseases and illnesses of parents
Immunizations
Tuberculosis
Diabetes
Anemia
Cancer
Rheumatic Fever
Heart disease
Disease of
nervous system
Overweight
Underweight
Others
If not living, give
date and cause
of death
Brother and Sisters
Name:
Date of birth: Serious
illnesses:
Date:
Date:
Date:
Smallpox
Diphtheria
Whooping
cough
Tetanus
Polio
Typhoid
Tests
Test:
Schick
(Diphtheria)
Tuberculin
X-ray
Laboratory
Examination
Other
Blood Type:
Date:
Results:
Rh Factor:
Allergies:
Operations and Accidents
Accident/Operation Date:
Serious
Aftereffects: