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