Medical History Page 2
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1
2Major Injury/Major Illness
Place
Year
___________________________________________________________________
Family History
Underline, if any family history of the following:
Sugar diabetes, tuberculosis, high blood pressure, stroke, thyroid disorder, cancer, psychiatric problem,
bleeding tendency, polyps in colon, colitis, high cholesterol, heart attack.
Name of Family Member
Living?
Age
Details
Mother
Father
Brothers/Sisters
Children
Personal History
What is your occupation?
Does your occupation involve exposure to any hazardous materials, chemicals or body fluid
If yes, give details
contact, etc.?
Yes
No
Do you exercise or does your work involve manual activity?
Yes
No
Your education level
Do you smoke?
Yes
No
If no, did you ever smoke in the past? Yes
No
If yes, how many and for how long?
Date quit?
Do you consume alcohol? Yes
No
If no, did you drink in the past? Yes
No
Date you quit?
Do you consume extreme amounts of coffee, tea, or cola products? If yes, give details:
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