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Adult Medical History
Name
*
Date of birth:
*
+
Today's Date
*
+
Are you Under medical treatment now?
*
Are you taking any medication(s) including non-prescription medicine?
Health History
List of Allergies
*
Completion
Please Select "Y" for Yes, "N" for No
*
Y
N
Abnormal Bleeding
Y
N
High Blood Pressure
Y
N
Heart Attack
Y
N
Tuberculosis
Y
N
Pneumonia
Y
N
Rheumatic fever
Y
N
Kidney diseases
Y
N
Hives
Y
N
Hay fever/Allergies
Y
N
Asthma
Y
N
Emphysema
Y
N
Arthritis
Y
N
AIDS or HIV Infection
Y
N
Heart disease
Y
N
Stomach Troubles/Ulcer
Y
N
Cancer
Y
N
Diabetes
Y
N
Swollen Ankles
Y
N
Fainting/Seizures
Y
N
Low Blood Pressure
Y
N
Leukemia
Y
N
Epilepsy/Convulsions
Y
N
Cardiac Pacemaker
Y
N
Allergies
Y
N
Thyroid Problem
Y
N
Frequently Tired
Y
N
Angina
Y
N
Heart Murmur
Y
N
Anemia
Y
N
Mitral Valve Prolapse
Y
N
Sexually Transmitted Disease
Y
N
Joint Replacement or Implant
Y
N
Respiratory Problems
Y
N
Heart Trouble
Y
N
Liver Disease
Y
N
Weight Loss
Y
N
Glaucoma
Y
N
Radiation Therapy
Y
N
Stroke
Y
N
Easily Winded
Y
N
Chest Pains
Y
N
Hepatitis/Jaundico
Y
N
Signature of patient (or parent/guardian if minor)
*
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