Medical History Checklist

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Medical History Checklist

Patient Name:

Date:

Medical History

Medical History (Cont.)

Alcoholism

¨ Yes

¨ No

Hypertension

¨ Yes

¨ No

Alzheimer’s

¨ Yes

¨ No

Hyperthyroidism

¨ Yes

¨ No

Amblyopia

¨ Yes

¨ No

Hypothyroidism

¨ Yes

¨ No

Anaphylaxis

¨ Yes

¨ No

Immune Deficiency

¨ Yes

¨ No

Anemia

¨ Yes

¨ No

Infections (chronic)

¨ Yes

¨ No

Aneurysm

¨ Yes

¨ No

Infertility

¨ Yes

¨ No

¨ Yes

¨ No

¨ Yes

¨ No

Arrhythmia

Insomnia

¨ Yes

¨ No

¨ Yes

¨ No

Arthritis

Ischemic Bowel Disease

Asthma

¨ Yes

¨ No

Kidney Stones

¨ Yes

¨ No

Biliary Tract Disease

¨ Yes

¨ No

Lupus

¨ Yes

¨ No

¨ Yes

¨ No

¨ Yes

¨ No

Bipolar Disorder

Lyme Disease

Blindness

¨ Yes

¨ No

Macular Degeneration

¨ Yes

¨ No

Cancer

¨ Yes

¨ No

MAI

¨ Yes

¨ No

Cataplexy

¨ Yes

¨ No

Menopause

¨ Yes

¨ No

Cataracts

¨ Yes

¨ No

Multiple Sclerosis

¨ Yes

¨ No

Chronic Pain

¨ Yes

¨ No

Narcolepsy

¨ Yes

¨ No

Cirrhosis

¨ Yes

¨ No

Nephrotic Syndrome

¨ Yes

¨ No

Collapsed Lung

¨ Yes

¨ No

Ocular Misalignment

¨ Yes

¨ No

Colorblindness

¨ Yes

¨ No

Osteoporosis

¨ Yes

¨ No

Congestive Heart Failure

¨ Yes

¨ No

Ovarian Cysts

¨ Yes

¨ No

COPD

¨ Yes

¨ No

Pancreatitis

¨ Yes

¨ No

¨ Yes

¨ No

¨ Yes

¨ No

Coronary Artery Disease

Parkinson’s Disease

Crohn’s Disease

¨ Yes

¨ No

Peripheral Neuropathy

¨ Yes

¨ No

Cryptococcus

¨ Yes

¨ No

Pleural Effusion

¨ Yes

¨ No

¨ Yes

¨ No

¨ Yes

¨ No

Cystic Fibrosis

Prostate Enlarged

Cytomegalovirus

¨ Yes

¨ No

Prostatitis (chronic)

¨ Yes

¨ No

Degenerative Arthritis

¨ Yes

¨ No

Psoriasis

¨ Yes

¨ No

Depression

¨ Yes

¨ No

Pulmonary Embolism

¨ Yes

¨ No

Dermatitis

¨ Yes

¨ No

Pulmonary Fibrosis

¨ Yes

¨ No

Diabetes

¨ Yes

¨ No

Reflux Esophagitis

¨ Yes

¨ No

Ectopic Pregnancy

¨ Yes

¨ No

Renal Failure

¨ Yes

¨ No

Endometriosis

¨ Yes

¨ No

Retinal Detachment

¨ Yes

¨ No

Epilepsy

¨ Yes

¨ No

Rheumatoid Arthritis

¨ Yes

¨ No

Erectile Dysfunction

¨ Yes

¨ No

Sickle Cell Anemia

¨ Yes

¨ No

Gallstones

¨ Yes

¨ No

Sinusitis (chronic)

¨ Yes

¨ No

¨ Yes

¨ No

¨ Yes

¨ No

Glaucoma

Sleep Apnea

Glomerulonepritis

¨ Yes

¨ No

Somnambulism

¨ Yes

¨ No

Gout

¨ Yes

¨ No

Spina Bifida

¨ Yes

¨ No

Headaches

¨ Yes

¨ No

Stroke

¨ Yes

¨ No

Hearing Impairment

¨ Yes

¨ No

Thalassemia

¨ Yes

¨ No

Hepatitis A

¨ Yes

¨ No

Tinnitus

¨ Yes

¨ No

Hepatitis B

¨ Yes

¨ No

Toxoplasmosis

¨ Yes

¨ No

Hepatitis C

¨ Yes

¨ No

Tuberculosis

¨ Yes

¨ No

HIV

¨ Yes

¨ No

Ulcers

¨ Yes

¨ No

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