I Sleeping A B C D E F J Traveling A B C D E F Please CIRCLE any of the following diseases you may have had: Group 1 Hepatitis Shingles Group 2 Group 3 4 Anemia Measles Diphtheria Polio Whooping Cough Arthritis Hypertension Ulcer Migraine Headache Smallpox Emphysema Eczema Gallbladder Disease Pleurisy Chickenpox Asthma Tumor or Cancer Stroke Malaria Colitis Heart Disease Bursitis Diabetes Gout Diverticulitis Pneumonia Tuberculosis Mumps Rheumatic Fever Epilepsy Rheumatism Hernia Venereal Disease Neuritis Osteoporosis Typhoid Fever Kidney Disease Hay Fever Hypoglycemia Scarlet Fever Obstruction Encephalitis Thyroid Disease Alcoholism Meningitis Chemical Dependency Other: _______________________________________________________________________________ Are You Pregnant? Y N Surgical History: Indicate the Year Family Health History:
I Sleeping A B C D E F J Traveling A B C D E F Please CIRCLE any of the following diseases you may have had: Group 1 Anemia Measles Arthritis Smallpox Pleurisy Stroke Bursitis Pneumonia Epilepsy Neuritis Hay Fever Hepatitis Group 2 Diphtheria Hypertension Emphysema Chickenpox Malaria Diabetes Tuberculosis Rheumatism Osteoporosis Hypoglycemia Encephalitis Meningitis Group 3 Polio Ulcer Eczema Asthma Colitis Gout Mumps Hernia Typhoid Fever Scarlet Fever Thyroid Disease Shingles 4 Whooping Cough Migraine Headache Gallbladder Disease Tumor or Cancer Heart Disease Diverticulitis Rheumatic Fever Venereal Disease Kidney Disease Obstruction Alcoholism Chemical Dependency Other: _______________________________________________________________________________ Are You Pregnant? Y N Surgical History: Indicate the Year Family Health History: