Patient Medical History Survey.

Personal Information Name:   Address:   Phone:   Date:   Age:   Sex Male Female HISTORY OF PAST ILLNESS: Check all that you have had. Childhood Measles Mumps Chicken Pox Congenital Abnormalities Rheumatic fever or heart disease Adult Asthma Diabetes Tuberculosis Blood Problem Heart Attack High Blood Pressure Ulcer or Gastritis Kidney Problem Venereal Disease Abnormal Heart Rhythm Thyroid Problems Liver Problems Heart Failure Cancer (where was the cancer?)   If any of the following are positive, please explain   No Yes If yes, please explain Have you ever had any serious illness? Have you ever had a transfusion? Have you ever been hospitalized or been under medical care for very long? Most recent immunizations (fill in dates) Hepatitis B   Flu Vaccine   Tetanus   Pneumovax   OPERATIONS Have you ever had any surgery? No Yes Surgeries you have had