Hearing Loss Hypoglycemia Infectious Mononucleosis Jaundice or Hepatitis Malaria Neurological Issues – Specify: Head Injury – Specify: Concussion – Specify: Fracture – Specify: Unconsciousness – Specify Other – Specify: Neck Injury – Specify: Fracture – Specify: Pinched Nerve – Specify: Other – Specify: Orthopedic Problems – Specify: Ankle – Specify: Arm / Elbow / Wrist / Hand/Fingers – Specify: Back/Ribs – Specify: Foot – Specify: Hip / Groin – Specify: Knee – Specify: Lower Leg – Specify: Shoulder – Specify: Thigh – Specify: Other (Stress Fracture, Etc.) – Specify: Paralysis Personal Trauma Pilonidal Cyst Sexually Transmitted Disease – Specify: Smoke - Number of Cigarettes a Day:______ Thyroid Problems – Specify: Tuberculosis Urinary / Kidney Problems – Specify: Other health problems including hospitalizations or surgical operations – Specify: Have you ever had episodes of unexplained shortness of breath, wheezing or chest pain? – Specify: Are you taking any medications routinely? – Specify: Please mark “YES” if any organs are NOT intact – Specify: Eyes Kidneys Lungs Testes (Ovaries / Testicles) Other – Specify: If there is other medical history important to your safety or to the safety of others, please report it below: THIS SECTION TO BE COMPLETED BY FEMALES ONLY: Have you ever had any gynecological / obstetrics issues? – Specify: Are you pregnant? Menstrual Disorder – Specify: Part III – MENTAL HEALTH/SOCIAL HISTORY
Hearing Loss Hypoglycemia Infectious Mononucleosis Jaundice or Hepatitis Malaria Neurological Issues – Specify: Head Injury – Specify: Concussion – Specify: Fracture – Specify: Unconsciousness – Specify Other – Specify: Neck Injury – Specify: Fracture – Specify: Pinched Nerve – Specify: Other – Specify: Orthopedic Problems – Specify: Ankle – Specify: Arm / Elbow / Wrist / Hand/Fingers – Specify: Back/Ribs – Specify: Foot – Specify: Hip / Groin – Specify: Knee – Specify: Lower Leg – Specify: Shoulder – Specify: Thigh – Specify: Other (Stress Fracture, Etc.) – Specify: Paralysis Personal Trauma Pilonidal Cyst Sexually Transmitted Disease – Specify: Smoke - Number of Cigarettes a Day:______ Thyroid Problems – Specify: Tuberculosis Urinary / Kidney Problems – Specify: Other health problems including hospitalizations or surgical operations – Specify: Have you ever had episodes of unexplained shortness of breath, wheezing or chest pain? – Specify: Are you taking any medications routinely? – Specify: Please mark “YES” if any organs are NOT intact – Specify: Eyes Kidneys Lungs Testes (Ovaries / Testicles) Other – Specify: If there is other medical history important to your safety or to the safety of others, please report it below: THIS SECTION TO BE COMPLETED BY FEMALES ONLY: Have you ever had any gynecological / obstetrics issues? – Specify: Are you pregnant? Menstrual Disorder – Specify: Part III – MENTAL HEALTH/SOCIAL HISTORY
health-record-portal-copy-2015-2016.docx