Medical History Page 2
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5Asthma
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_____
Seasonal allergies
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Seizures or Epilepsy
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Venereal disease (type)
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HIV or AIDS
________________________________________________________________________
Liver disease
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Hepatitis (type)
_______________________________________________________________________
Major surgery (type)
__________________________________________________________________
Blood transfusion
_____________________________________________________________________
Blood disorder (anemia, leukemia)
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Bleeding problems
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Diabetes
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Arthritis (type)
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Cancer (type)
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Chemotherapy
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Radiation therapy
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Thyroid
disorder_________________________________________________________________
_____
Kidney disorder
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Stomach ulcers
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Mouth ulcers
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Osteoporosis_____________________________________________________________
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