Health History Form

Name
DOB
Please fill in the box of any of the following illnesses and medical problems you have or have had and indicate the year when each started. If you are not certain when an illness started, enter an approximate year.

	Y/N	Year
Allergies or Hay Fever
Anemia
Anxiety/Panic Attack
Arthritis
Benign Tumor
Bleeding Tendency
Breast Lumps or Fibrocystic Dis.
Cancer
Chronic Bronchitis
Convulsions, Seizures
Deafness or Decreased Hearing
Depression
Diabetes
Diverticulosis
Emphysema
Gallbladder Trouble
Glaucoma
Gout
Headaches
Head Injury
Heart Attack
Hemorrhoids
Hepatitis/Jaundice
Hernia
High Blood Pressure
High Cholesterol
Irritable Bowel Syndrome
Kidney or Bladder Disease
Kidney Stones
Life Threating Allergies
Liver Trouble
Lung Problems
Pneumonia
Prostate Problems (male only)
Sexually Transmitted Disease Skin
Problems
Thyroid trouble
Tuberculosis
Ulcerative Colitis or Chrones Disease
Asthma