Name:
Birth Date:
Please check if you currently have or have had these symptoms within the past year.
GENERAL
GENITO-URINARY
Chills
Blood in Urine
Depression
Frequent Urination
Dizziness
Loss of Bladder Control
Fainting
Painful Urination
Fever
GASTROINTESTINAL
Headache
Poor Appetite
Nervousness
Bloating
Numbness
Bowel Changes
Sleep Loss
Constipation
Sweats
Diarrhea
Weight Loss
Gas
SKIN
Hemorrhoids
Bruises
Indigestion
Hives
Nausea
Itching
Rectal Bleeding
Moles
Stomach Pain
Rash
Vomiting
CARDIOVASCULAR
Vomiting Blood
Chest Pain
MEN ONLY
High Blood Pressure
Breast Lump
Irregular Heart Beat
Erection Difficulties
Poor Circulation
Testicular Lump
Ankle Swelling
Discharge
Varicose Veins
Sores
EYES, EARS, NOSE, THROAT
WOMEN ONLY
Bleeding Gums
Abnormal PAP Smear
Crossed Eyes
Bleeding Between Periods
Difficulty Swallowing
Breast Lump
Ear Pain
Extreme Menstrual Pain
Ringing
Hot Flashes
Discharge
Painful Intercourse
Vision Charges
Vaginal Discharge
Hay Fever
Nipple Discharge
Hoarseness
HEALTH HABITS
Hearing Loss
Caffeine
Nosebleeds
Tobacco
Sinus Problems
Drugs
Cough
Exercise
AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Breast Lump
Bronchitis
Bulimia
Cancer
Cataracts
Polio
Please check conditions you have had in the past.
Addiction
High Cholesterol
Prostate Problem
Chicken Pox
HIV Positive
Psychiatric Care
Diabetes
Kidney Disease
Rheumatic Fever
Emphysema
Liver Disease
Scarlet Fever
Epilepsy
Measles
Stroke
Glaucoma
Migraines
Suicide Attempt
Goiter
Miscarriage
Thyroid Problem
Gonorrhea
Multiple Sclerosis
Bleeding Disorder
Gout
Mononucleosis
Tonsillitis
Heart Disease
Mumps
Typhoid Fever
Hepatitis
Pacemaker
Ulcers
Herpes
Pneumonia
Vaginal Discharge
Hernia
Venereal Disease
Vaginal Infection
HOSPITAL
RELATION
Father
Mother
Sibling(s)
AGE
Please list prior hospitalizations.
YEAR
REASON
Please list your family history.
STATE OF HEALTH
CAUSE OF DEATH
Please check if any blood relatives have had any of the following conditions.
Arthritis
Tuberculosis
Asthma
Hay Fever
Cancer
Addiction
Diabetes
Heart Disease
Stroke
High Blood Pressure
Kidney Disease
Other