Personal Health History

Gender:_____M   _____F

Age:_____     Race:_____________________

Personal Health History:  check those that apply

___  Heart Disease                                                                    Diseases
___  Heart Defect
___  Diabetes                                                                             ___  Chicken Pox
___  Arthritis                                                                              ___  Measles (Rubeola)
___  Hypertension                                                                      ___  Mumps
___  Stroke                                                                                ___  German Measles (Rubella)
___  Convulsive Disorder                                                           ___  Scarlet Fever
___  Ear Infections                                                                     ___  Rheumatic Fever
___  Bleeding/clotting Disorders                                                  ___  Mononucleosis
___  Lupus
___  Hypoglycemia                                                                 Genetic Disorders (family)
___  Frequent Urinary Infections                                           ___  Alcoholism
___  Asthma                                                                         ___  Down's Syndrome
___  Severe Headaches                                                        ___  Hemophilia
___  Anemia                                                                         ___  Sickle-cell Anemia
___  Other                                                                            ___  Phenylketonuria (PKU)
                                                                                             ___  Cystic Fibrosis

Allergies                                                                              Behaviors
___  Food related                                                                ___  Smoker
___  Insect stings                                                                 ___  Drink more than 14 alcoholic
___  Plant allergies (poison ivy, etc.)                                             beverages per week
___  Hay fever (dust, pollen)                                                ___  Exercise less than 3 x's per wk.
___  Allergies to animals                                                      ___  Poor stress management
___  Metals

Operations and  Serious Injuries

Operations:(those that apply to you)                                                             Date:

1.  ____________________________________________________    _____
2.  ____________________________________________________     _____
3.  ____________________________________________________     _____
4.  ____________________________________________________     _____
 
Injuries: (those that apply to you)                                                                  Date:

1.  ____________________________________________________    _____
2.  ____________________________________________________    _____
3.  ____________________________________________________    _____
4.  ____________________________________________________    _____

Current Medications

1.  ____________________________________________________
2.  ____________________________________________________
3.  ____________________________________________________
4. ____________________________________________________
 

Family Health History

For the following categories list the number of family members diagnosed and their relationship (father, mother, etc.) with each disease and the ages diagnosed with the disease.  If deceased, age of death.  The more family members and the earlier their deaths the greater risk to you.
 

Family Member Heart Disease Hyper-tension Stroke Diabetes Cancer
 Other Age of Death Cause of Death