Uab Student Health And Wellness Health History Form Page 2
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4Family & Personal Health History (to be completed by the student)
Has any person, related by blood, had any of the following?
Yes
No
Relationship
Yes No
Relationship
High Blood Pressure
Cholesterol or blood fat disorder
Stroke
Blood clotting disorder
Cancer
Psychiatric
Heart attack before age 55
Suicide
Diabetes
Alcohol/drug problems
Glaucoma
Have you ever had or now have: (please check at right of each item and if yes, indicate year of first occurrence)
Yes
No
Symptom
Year
Yes
No
Symptom
Year
High Blood Pressure
Mononucleosis
Rheumatic fever
Hay fever
Heart trouble
Head/neck radiation
Pain/pressure in chest
Arthritis
Shortness of breath
Concussion
Asthma
Frequent/severe headache
Pneumonia
Dizziness/fainting spells
Chronic cough
Severe head injury
Tuberculosis
Paralysis
Tumor/cancer (specify)
Epilepsy/seizures
Malaria
Blood transfusion
Thyroid trouble
Protein in blood or urine
Serious skin disease
Ulcer (duodenal/stomach)
Hearing loss
Intestinal trouble
Sexually transmitted disease
Pilonidal cyst
Severe menstrual cramps
Allergy injection therapy
Irregular periods
Back injury
Frequent vomiting
Broken bones
Gall bladder or gallstones
Kidney infection
Jaundice or Hepatitis
Bladder infection
Rectal disease
Kidney stone
Mental Health History
Severe/recurrent abdominal pain
Sinusitis
Sleep problems
Hernia
Self-injurious Behavior
Chicken pox
Depression/bipolar
Anemia/Sickle Cell Anemia
Anxiety/panic
Eye trouble besides glasses
LD/ADD/ADHD
Bone, joint, other deformity
Eating Disorder
Shoulder dislocation
Obsessive compulsive
Knee problems
Self-induced vomiting
Substance Use History
Recurrent back pain
Neck injury
Alcohol/drug problem
Diabetes
Smoke 1+ pack cigs/week
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Parent category: Medical