Form Hbc53 - Home Delivery Form (Hmq Questionnaire) Page 4
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4Section 3: Medical Conditions
Please list in the appropriate column the names of each family member enrolled. Then, for each
family member, fill in the circle next to each condition if a doctor ever said that particular family
member has that condition.
Member
Spouse Dependent Dependent Dependent
First Name:
Heart failure (weak heart)
High blood pressure (hypertension)
Heart attack or angina
High cholesterol
(hypercholesterolemia)
Stroke
Chronic bronchitis or emphysema
(COPD)
Asthma
Allergies, runny nose, hay fever
(allergic rhinitis)
High blood sugar (diabetes)
Thyroid disease
Peptic, stomach, or duodenal ulcer
Gastric reflux, heartburn,
or esophagitis (GERD)
Inflammatory bowel disease
(colitis, Crohn’s disease)
High pressure in the eyes
(glaucoma)
Seizures
Poor circulation in the legs
(peripheral vascular disease)
Trouble with blood not clotting
properly
Enlarged prostate
(benign prostatic hyperplasia, BPH)
Arthritis
Osteoporosis
Depression
Migraine Headaches
Print other medical conditions not
listed above in the space provided
(e.g., cancer)
Please return the questionnaire with your prescription or refill order form.
Did you complete both sides?
Thank you very much.
HBC53
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