medical history MEDICAL HISTORY

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medical history MEDICAL HISTORY Powered By Docstoc
					                                           MEDICAL HISTORY


Condition                    YES   NO   Description (if   Start Year of   Still Present?   If still present,
                                        needed)           Diagnosis or    (circle one)     is medication
                                                          Condition                        required?
Seasonal Allergies                                                        Yes or No        Yes or No
Drug Allergies (Please                                                    Yes or No        Yes or No
List)
   Other allergies?                                                       Yes or No        Yes or No
HEENT Disorders
   History of HA’s                                                        Yes or No        Yes or No
   Other                                                                  Yes or No        Yes or No
Cardiovascular
   HTN                                                                    Yes or No        Yes or No
   CAD                                                                    Yes or No        Yes or No
   Stroke                                                                 Yes or No        Yes or No
   Other                                                                  Yes or No        Yes or No
Respiratory
   Asthma                                                                 Yes or No        Yes or No
   TB                                                                     Yes or No        Yes or No
   Pneumonia                                                              Yes or No        Yes or No
   Chronic Pulmonary                                                      Yes or No        Yes or No
Disease
  Other                                                                   Yes or No        Yes or No

Endocrine & Metabolic
   Diabetes Mellitus                                                      Yes or No        Yes or No
   Thyroid Disorder                                                       Yes or No        Yes or No
   Pancreatic disorder                                                    Yes or No        Yes or No
   Other                                                                  Yes or No        Yes or No
Immune System
   AIDS                                                                   Yes or No        Yes or No
  Collagen Vascular                                                       Yes or No        Yes or No
Disease
   Other                                                                  Yes or No        Yes or No
Hematology & Lymphatic
   Thrombocytopenia                                                       Yes or No        Yes or No
   Anemia                                                                 Yes or No        Yes or No
   Cancer                                                                 Yes or No        Yes or No
   Lymphoma                                                               Yes or No        Yes or No
   Other                                                                  Yes or No        Yes or No
Dermatological
   Rashes                                                                 Yes or No        Yes or No
   Lesions                                                                Yes or No        Yes or No
Musculoskeletal
    Pain                                                                  Yes or No        Yes or No
    Arthritis                                                             Yes or No        Yes or No
   Weakness                                                               Yes or No        Yes or No
   Other                                                                  Yes or No        Yes or No
Gastrointestinal/Digestive
   GERD                                                                   Yes or No        Yes or No
   Hepatitis A, B or C                                                    Yes or No        Yes or No
   Peptic Ulcer Disease                                                   Yes or No        Yes or No
   Other                                                                  Yes or No        Yes or No
Genitourinary
   Kidney stones                                                          Yes or No        Yes or No
   Renal Insuffiency                                                      Yes or No        Yes or No
Condition                 YES   NO   Description   Start Year of   Still Present?   If still present,
                                                   Diagnosis or    (circle one)     is medication
                                                   Condition                        required?
   Prostate disorder                                               Yes or No        Yes or No
  Other                                                            Yes or No        Yes or No
Neurologic/ Psychiatric
   Depression                                                      Yes or No        Yes or No
   Anxiety                                                         Yes or No        Yes or No
   Seizures                                                        Yes or No        Yes or No
   Other neurologic                                                Yes or No        Yes or No
Procedures/surgical
history
                                                                   Yes or No        Yes or No
                                                                   Yes or No        Yes or No
                                                                   Yes or No        Yes or No
Other Medical History
                                                                   Yes or No        Yes or No
                                                                   Yes or No        Yes or No
                                                                   Yes or No        Yes or No

				
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posted:11/11/2011
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