Previous Illnesses/Surgical History

Did you ever have:
yes/no
when?
Did you ever have:
yes/no
when?
Blood Transfusion
n
High Blood Pressure
n
Measles
y
 5 years old
Venereal Disease
n
Mumps
y
 6 years old
Kidney Disease
n
Chickenpox
y
 4 years old
Epilepsy
n
Scarlet Fever
n
Anemia
n
Rheumatic Fever
n
Surgeries
Tonsillectomy
2 Caesarean sections
Hysterectomy
/
6 years of age
2 and 6 years ago
1 year ago;
dysfunctional uterine bleed
Diabetes
n
Other
Asthma 
 resolved at 12 yr of age
Heart Disease
n
Other
 Last summer had traveler's diarrhea Rx with flagyl and resolved.

Immunizations: Tetanus shot 5 years ago, pneumovax 15 years ago, annual Influenza vaccine

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©1999,  Herbert A. Yates, D.O. and Neal R. Chamberlain, Ph.D.. All rights reserved.