PAST MEDICAL AND FAMILY HISTORY FORM

Patient Name: ________________________________ Date: ______________

DOB: ____________

PLEASE CHECK IF YOU OR ANY BLOOD RELATIVE HAD ANY OF THE

FOLLOWING: (please specify who)

1. Weight Loss or Gain _________Self ________Family _________________

2. Headaches/Migraines _________Self ________Family _________________
3. Heart Disease _________Self ________Family _________________
4. Valvular Disorder _________Self ________Family _________________
5. Rheumatic Disorder _________Self ________Family _________________
6. High Blood Pressure _________Self ________Family _________________
7. Respiratory Disease _________Self ________Family _________________
8. Pulmonary (Lung) Disease _________Self ________Family _________________
9. Breast Disease _________Self ________Family _________________
10. Jaundice/Hepatitis _________Self ________Family _________________
11. Hiatal Hernia (Reflux) _________Self ________Family _________________
12. Peptic Ulcer (Stomach) _________Self ________Family _________________
13. Bowel Disease _________Self ________Family _________________
14. Kidney Disease _________Self ________Family _________________
15. Urinary Incontinence _________Self ________Family _________________
16. Urinary Infections _________Self ________Family _________________
17. Blood Transfusions _________Self ________Family _________________
18. Anemia/Blood Disorder _________Self ________Family _________________
19. Varicose Veins/Phlebitis _________Self ________Family _________________
20. Skin Diseases _________Self ________Family _________________
21. Diabetes _________Self ________Family _________________
22. Thyroid Disease _________Self ________Family _________________
23. Cancer (type) ____________ _________Self ________Family _________________
24. Epilepsy/Neurologic Disorder _________Self ________Family _________________
25. Arthritis/Joint Pain _________Self ________Family _________________
26. Osteoporosis/Fragile Bones _________Self ________Family _________________
27. Anxiety/Depression _________Self ________Family _________________
28. Sleep Problems _________Self ________Family _________________
29. Other:
Please Explain: _____________________________________________________________
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