Medical History Form - Adult Missions Ministry Team Page 2
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1
2f.
Fainting spells or seizures
Yes
No
g.
Persistent diarrhea or recent weight loss
Yes
No
h.
Diabetes
Yes
No
i.
Hepatitis, jaundice or liver disease
Yes
No
j.
AIDS or HIV infection
Yes
No
k.
Thyroid problems
Yes
No
l.
Respiratory problems, emphysema, bronchitis, etc.
Yes
No
m.
Arthritis or painful swollen joints
Yes
No
n.
Stomach ulcer or hyperactivity
Yes
No
o.
Kidney trouble
Yes
No
p.
Tuberculosis
Yes
No
q.
Persistent cough or cough that produces blood
Yes
No
r.
Persistent swollen glands in neck
Yes
No
s.
Low blood pressure
Yes
No
t.
Sexually transmitted disease
Yes
No
u.
Epilepsy or other neurological disease
Yes
No
v.
Problems with mental health
Yes
No
w.
Cancer
Yes
No
x.
Problems of the immune system
Yes
No
Have you had abnormal bleeding?
Yes
No
9.
a. Have you ever required a blood transfusion?
Yes
No
Do you have any blood disorder such as anemia?
Yes
No
10.
Have you ever had any treatment for a tumor or growth?
Yes
No
11.
Are you allergic or have you had a reaction to:
12.
Local anesthetics
Yes
No
a.
Penicillin or other antibiotics
Yes
No
b.
Sulfa drugs
Yes
No
c.
Barbiturates, sedatives or sleeping pills?
Yes
No
d.
Aspirin
Yes
No
e.
Iodine
Yes
No
f.
Codeine or other narcotics
Yes
No
g.
Other
h.
Do you have any disease, condition, or problem not listed above that you think I
13.
should be aware of?
Yes
No
If so, explain.
Are you wearing contact lenses?
Yes
No
14.
Are you wearing removable dental appliances?
Yes
No
15.
I certify that I have read and understand the above. I acknowledge that my questions, if
any, about the inquiries set forth above have been answered to my satisfaction. I will not
hold the Northwest Chapel staff responsible for any errors or omissions that I may have
made in the completion of this form.
__________________________________________________
Signature
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