Uc Hastings Shs Personal Health History Questionnaire Page 2
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2PERSONAL HEALTH HISTORY QUESTIONNAIRE (page two)
MEDICAL HISTORY
Check the conditions below which you have now, or have had in the past. Indicate the year you first experienced symptoms/onset.
abnormal pap smear
diabetes
pregnancy
acne (severe)
eating disorders
psychological problems
alcohol/substance abuse
eczema or psoriasis
seizures
allergies needing medication
headaches (migraine)
sexually transmitted infection
ADD/ADHD
heart disease
smoker presently
Anxiety or depression
hepatitis
thyroid disorder
asthma
Herpes Simplex
tuberculosis or (+) test
bleeding disorder
high blood pressure
ulcers
blood clot in vein
intestinal disorder
urinary tract disease
cancer or tumor
mononucleosis
none of the above
chicken pox
pneumonia/lung problems
other_______________________
Briefly give details of any of the conditions you have checked.
Please tell us if you have any conditions/physical restrictions or other health problems (including emotional and/or mental
health) which require special arrangements.
SURGICAL, HOSPITALIZATION, TRAUMA HISTORY
Please list the type and date of any surgeries, hospitalizations, or serious injuries you have had.
FAMILY HISTORY Please indicate which if any blood relatives (i.e. parents, grandparents, siblings) have had the following
diseases:
Intestinal Disorder
Alcohol/Drug Abuse
Asthma
Kidney Disease
Bleeding Disorder
Mental Illness
Blood clot in leg or lung
Migraine headaches
Cancer
Neurologic Disorder
Depression
Premature death
Diabetes
Stroke
Eating Disorder
Suicide attempt
Gynecologic problems
Thyroid disease
Heart Disease
Other
High Cholesterol
Unknown
Hypertension
I certify that to the best of my knowledge this information is complete and accurate.
__________________________________________________ ____________________________
Student's Signature Date
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