Personal Medical History

Personal medical history

Score

Past medical history

For each condition, score 0 if none exists or successfully treated and reported, 1 if untreated and/or unreported

Allergies or Asthma

 

Alcoholism *

 

Anemia

 

Arthritis

 

Breast lumps/cysts

 

Cancer (Tumors)

 

Cataracts

 

Congestive Heart Failure

 

Depression

 

Diabetes

 

Drug Abuse

 

Eczema-Hives

 

Epilepsy or Seizures

 

Heart Attack

 

Hemorrhoids

 

Hepatitis (Jaundice)

 

High Blood Pressure

 

Heart Blockage

 

Kidney Stones

 

Liver Disease

 

Lung Disease

 

Migraines

 

Phlebitis

 

Psoriasis

 

Hernia

 

Stroke

 

Suicide Attempt

 

Thyroid Disease

 

Other

 

Current medications

Score 0 if none taken, or if the medications are necessary to stabilize medical conditions. Score 1 for each medication if it is not yet known to stabilize the medical condition.

 

Drug allergies

For each drug allergy, score 0 if known and reported to all attending physicians, otherwise 1

 

Symptoms within last 6 months

For each symptom, score 1 if present, otherwise 0

General fatigue, weight loss, melancholy, apathy, or depression

 

Ears, Nose, Throat (Drainage, bleeding, hard to swallow, etc.)

 

Lungs or Breathing (Shortness of breath, cough, wheeze, etc.)

 

Heart (chest pains, murmur, skipping, etc.)

 

Bones/Joints (swelling, stiffness, pain, etc.)

 

Skin (rashes, ulcers, etc.)

 

Overall score

 

 

*There is no safe level of alcohol consumption. Habitual consumption of 1 drink (e.g., a glass of wine, a regular can/bottle of beer, a shot of hard liquor) per day is potentially hazardous and should be score 1.

Reminder: Accumulated score of zero requires no further action. The user is encouraged to discuss with a healthcare provider any line items scored as 1 and proceed with remedial actions as appropriate. Save or print the table. All forms will reset to blank state once the user exits the website.

"Prevention is better than cure" Desiderius Erasmus