X hits on this document

38 views

0 shares

0 downloads

0 comments

10 / 14

PERSONAL MEDICAL HISTORY

HAVE YOU EVER BEEN DIAGNOSED OR TREATED FOR ANY OF THE FOLLOWING CONDITIONS? (PLEASE PLACE A CHECK NEXT TO CONDITION)

______ASTHMA ______ALLERGIES ______ALZHEIMER’S DISEASE ______ANEURYSM ______ARTHRITIS ______ANEMIA ______ANOREXIA/BULIMIA ______ADD/ADHD ______ANXIETY ______BALANCE TROUBLE ______BI-POLAR DISORDER ______BRONCHITIS ______CANCER______________________ ______CARPAL TUNNEL SYNDROME ______CATARACTS ______CEREBRAL PALSY ______CIRRHOSIS ______COLITIS ______CONSTIPATION ______CHRONIC LUNG DISEASE ______DEPRESSION ______DIABETES ______DIARRHEA ______DIZZINESS/VERTIGO ______DEMENTIA ______DRUG ABUSE __________________ ______EAR INFECTIONS ______EMPHYSEMA ______EYE DISEASE ______EPILEPSY/SEIZURES ______FAINTING/SYNCOPE ______FIBROMYALGIA ______GASTROESOPHAGEAL REFLUX ______GLAUCOMA ______HALLUCINATIONS ______HEADACHES ______HEAD INJURY ______HEART DISEASE ______HERPES SIMPLEX VIRUS

______HEART ATTACK ______HEMORRHOIDS ______HEPATITIS ______HIGH CHOLESTEROL ______HIGH/LOW BLOOD PRESSURE ______LOW BLOOD SUGAR ______HIV POSITIVE ______HEARING DIFF./CHANGES ______KIDNEY CONDITIONS ______MENINGITIS ______MENTAL RETARDATION ______MENTAL ILLNESS ______MUSCLE CONDITIONS ______MULTIPLE SCLEROSIS ______OBESITY ______OBSESSIVE COMP. DISORDER ______OSTEOPOROSIS ______PARKINSON’S DISEASE ______PELVIC INFLAMMATORY DISEASE ______PNEUMONIA ______PROSTATE CONDITIONS ______RINGING IN EARS/TINNITUS ______SPINE DISORDER/BACK PAIN ______STROKES/PIN STROKES/TIA ______SWELLING OF ARMS AND LEGS ______SEXUALLY TRANSMITTED DISEASE

______ ______ ______ ______ ______ ______

______ ______

(PLEASE LIST BELOW) SKIN CONDITIONS SUICIDE IDEATIONS / ATTEMPTS THYROID DISEASE TREMORS/SHAKING ULCERS URINARY / BOWEL CONDITIONS INCONTINENCE INFECTIONS URGENCY VISUAL DISTURBANCES VASCULAR CONDITIONS

EXPLAIN:

__________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Document info
Document views38
Page views38
Page last viewedWed Dec 07 09:28:00 UTC 2016
Pages14
Paragraphs403
Words4746

Comments