Medical History Form Page 3
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710815 Bathurst St., Richmond Hill, ON L4C 9Y2
Tel.: 905-737-5559, fax: 905-737-5556
Goiter
Y P
N
Pain or stiffness
Y P
N
9. RESPIRATORY
Cough
Y P
N
Sputum
Y P
N
Spitting up blood
Y P
N
Wheezing
Y P
N
Asthma
Y P
N
Bronchitis
Y P
N
Pneumonia
Y P
N
Pleurisy
Y P
N
Emphysema
Y P
N
Difficulty breathing
Y P
N
Pain on breathing
Y P
N
Shortness of breath
Y P
N
Shortness of breath at night
Y P
N
Shortness of breath lying down
Y P
N
Tuberculosis
Y P
N
Tuberculin Test
Y P
N
Last Chest -ray
10. CARDIOVASCULAR
Heart disease
Y P
N
Angina
Y P
N
High blood pressure
Y P
N
Murmurs
Y P
N
Rheumatic fever
Y P
N
Chest pain
Y P
N
Swelling in ankles
Y P
N
Palpitations, fluttering
Y P
N
Cyanosis
Y P
N
Past ECG
Y P
N
Other heart tests
11. BREASTS
Do you do self exams?
Y P
N
Lumps
Y P
N
Pain (or tenderness)
Y P
N
Nipple discharge
Y P
N
12. GASTROINTESTINAL
Trouble swallowing
Y P
N
Heartburn
Y P
N
Change in thirst
Y P
N
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Parent category: Medical