Medical Illnesses or Conditions (list any chronic conditions which you have been diagnosed to have) _______________________________________ __________________________________ ____________________________________ _______________________________________ __________________________________ ____________________________________ _______________________________________ __________________________________ ____________________________________ _______________________________________ __________________________________ ____________________________________ Have you ever had or been diagnosed to have: (please check any/all that apply) Cataracts Glaucoma Asthma Allergies Stroke Seizures/Epilepsy Heart Attack or Angina Heart Disease Heart Murmur High Blood Pressure Pneumonia TB/Lung Disease Pleurisy Jaundice or Liver Disease Ulcers Digestive Disorder Hemorrhoids Kidney Disease Kidney Stones Diabetes or Pre Diabetes Thyroid Disease Operations: Anemia Bleeding Disorders Bone or Joint Disease German Measles Rheumatic Fever Chicken Pox Syphilis Depression Frequent Infection Cancer High Cholesterol Prostate Enlargement Please list any surgeries and the approximate year Year Surgery Hospitalizations: Other than operations Year Reason ________ _______________________________________ _______ _____________________________________________ ________ _______________________________________ _______ _____________________________________________ ________ _______________________________________ _______ _____________________________________________ ________ _______________________________________ _______ _____________________________________________ ________ _______________________________________ _______ _____________________________________________ Family Medical History Age Health (list significant illness) Age at Death Hospital If deceased, cause of death? Comments Father Mother Brothers or Sisters Spouse Children Has any blood relative ever had? (Check if Yes and indicate the relationship to yourself) _____ Alzheimer’s ___________________ _____ Heart Attack before age 55 _____________________ _____ Alcoholism __________________ _____Tuberculosis ___________________ _____ Bleeding Disease _____________________________ _____ Mental Disorder_______________ _____Diabetes ______________________ _____ Stroke ______________________________________ _____ Allergies _____________________ _____High Blood Pressure_____________ _____ Seizures ____________________________________ _____ Asthma ______________________ _____Heart Disease__________________ _____ Depression/Suicide____________________________ _____ Cancer ______________________ Immunizations (check if Yes and indicate the year of your last injection) ____Influenza_________ ___Pneumonia__________ ___MMR__________ ___Tetanus_________ ___Hepatitis A or B_________ __Other_____ Transfusions: Have you ever had a blood or plasma transfusion? Please circle Yes or No Females only Are you pregnant, planning a pregnancy or currently nursing a child? Yes or No If yes, which _________________ Date of last Menstrual period?____________ [SunMed Primary Care 2015] Page 2