Medical History Form (Page 2 of 2) in pdf

Medical History (check all that apply):

 Multiple Sclerosis (MS)

 Cancer (type____________)

 Chronic Pain

 Parkinson’s

 Radiation therapy

 Developmental / Growth Problems

 High Blood Pressure

 Chemotherapy

 Vision Problems

 Alzheimer’s

 Thyroid problems

 Taste / Smell Changes

 Aneurysm

 Hearing Problems

 Learning disability

 Seizures / Epilepsy

 Kidney Problems

 Sleep apnea/Sleep problems

 Diabetes

 Circulation /Vascular problems

 Headaches

 Anemia

 Polio

 Lung / Breathing Problems

 Meningitis / Encephalitis

 Pacemaker / Defibrillator

 Poor appetite

 Heart Problems/Heart Attack

 Substance Use

 Head Injury

 Coma

 Infectious Disease (e.g. HIV/TB)

 Stroke

 TIA or “Mini-Stroke”

 Hallucinations

Current Symptoms (check yes/no):

 YES

 NO

Trouble remembering things

 YES

 NO

Difficulty in finding the right word or using wrong words

 YES

 NO

Being less able to manage money and finances (e.g., paying bills, budgeting)

 YES

 NO

Being less able to manage medications independently

 YES

 NO

Feeling depressed or other mood changes

 YES

 NO

Having sudden, short episodes of unconsciousness, memory loss, confusion

 YES

 NO

Having sudden, short episodes of jerking, falling, or other abnormal movements

 YES

 NO

Being less able to keep up with activities around the house

 YES

 NO

Problems walking or getting up from a chair

 YES

 NO

Problems with fine or small movements (like fastening buttons or writing)

 YES

 NO

Seeing or hearing things that others do not see or hear

 YES

 NO

Problems with posture, balance, or falls

 YES

 NO

Repeating questions, stories or conversations over and over

 YES

 NO

Changes in behavior or personality

 YES

 NO

Weakness, numbness or a “dead feeling” on one side of the body

 YES

 NO

Loss of vision, double vision, or other vision changes

 YES

 NO

Dizziness or vertigo (sense of rotation)

 YES

 NO

Losing the ability to understand what people were saying

 YES

 NO

Changes in the ability to speak or write

Medical History Form Page 2

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