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3Assessment Form
12. Have you even been diagnosed with or suspected to have any of the following by a Physician:
Condition
No
Yes (explain and indicate year diagnosed)
Don’t Know / Unsure
(explain)
Communicable diseases
(Hepatitis/HIV Aids)
Heart Disease (Heart Attack, Angina,
Heart Failure
Irregular Heart Beat
Shortness Breath
Asthma
Sleep Apnea
High Blood pressure
High Cholesterol
Bleeding Tendency
Cancer (Please specify)
Epilepsy
Depression/Emotional Stress
Arthritis?
Malignant Hyperthermia?
Diabetes Mellitus
Are you Pregnant?
13. Do you have a family history of:
Cardiovascular disease
☐ YES
☐ NO
Polyps
☐ YES
☐ NO
Cancer
☐ YES
☐ NO
If yes, please specify:
1-Relation:___________________Cancer of the: ___________at Age: __________
2-Relation:___________________Cancer of the: ___________at Age: __________
3-Relation:___________________Cancer of the: ___________at Age: __________
14. If your life is in danger due to severe blood loss, will you accept transfusion of blood, its components or products?
☐ YES
☐ NO **If NO, please speak to the receptionist immediately.
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Parent category: Medical