Name _________________________________  Current Date ___________

 
Please check if you or your family had/has any of the following:
  Yourself Other Family Member   Yourself Other Family Member
Anemia [  ] [  ] Hardening Arteries [  ] [  ]
Ankle Swelling [  ] [  ] Heart Problems [  ] [  ]
Arthritis [  ] [  ] Heart Disease [  ] [  ]
Asthma [  ] [  ] Hepatitis/Yellow Jaundice [  ] [  ]
Bladder Trouble/Infections [  ] [  ] High Blood Pressure/Hypertension [  ] [  ]
Bleeding Tendencies [  ] [  ] HIV (AIDS) [  ] [  ]
Bowel Problems [  ] [  ] Kidney Trouble [  ] [  ]
Cancer [  ] [  ] Nervous Disorder [  ] [  ]
Coughing up Blood [  ] [  ] Pneumonia [  ] [  ]
Chest Pain [  ] [  ] Shortness of Breath [  ] [  ]
Depression [  ] [  ] Seizure [  ] [  ]
Diabetes [  ] [  ] Sleep Disorder [  ] [  ]
Dizziness [  ] [  ] Stroke [  ] [  ]
Endocrine [  ] [  ] Skin [  ] [  ]
Emphysema [  ] [  ] Blood Clots [  ] [  ]
Epilepsy [  ] [  ] Ulcers [  ] [  ]
Other __________________________ Other __________________________
Other __________________________ Other __________________________
Please explain any of the above
____________________________________________________________
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Have you had a blood transfusion? [  ]Yes [  ]No Did you have a reaction? [  ]Yes [  ]No
Are you pregnant? [  ]Yes [  ]No Are you trying to get pregnant? [  ]Yes [  ]No
Approximate Height __________________ Approximate Weight __________________
Have you had a recent weight gain? [  ]Yes [  ]No Have you had a recent weight loss? [  ]Yes [  ]No
Do smoke or chew tobacco? [  ]Yes [  ]No How much a day? ___________________
Do you drink? [  ]Alcohol   How Much?
 ____________		 [  ]Beer    How Often? 
____________		  

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