Adult Health History Page 3
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9N O R T H E R N N E V A D A
HOPES
your partner in health.
Any allergies or intolerance to medications (include type of reaction)?:
I have no allergies
PERSONAL MEDICAL HISTORY: Do you have (now) or have you had (past) any of the following conditions?
NONE
Condition
Now
Past
Comments
Alcohol / Drug use
Allergy (Hay Fever)
Anemia
Anxiety
Arthritis (Rheumatoid)
Arthritis (Osteoarthritis)
Asthma
Bladder / Kidney Problems
Blood Clot (leg)
Blood Clot (lung)
Blood Transfusion
Breast Lump (benign)
Cancer Breast
Cancer Colon
Cancer Other Type
Cancer Ovarian
Cancer Prostate
Cataracts
Chicken Pox
Colon Polyp
Coronary Artery Disease
Depression
Diabetes (adult onset)
Diabetes (childhood onset)
Diverticulosis
Emphysema
Fractures (broken bones)
WHERE?:
Gallbladder Disease
Gastroesophageal Reflux
(Heartburn/GERD)
Glaucoma
Page 3 of 7
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