FAMILY HISTORY What medical problems do people in your family have? Family Medical Problems Member Mother: Diabetes (sugar) High blood pressure Heart problems ☐ ☐ ☐ Cancer other: ☐ ☐ Father: Diabetes (sugar) High blood pressure Heart problems ☐ ☐ ☐ Cancer other: ☐ ☐ Sisters: Diabetes (sugar) High blood pressure Heart problems ☐ ☐ ☐ Cancer other: ☐ ☐ Diabetes (sugar) High blood pressure Heart problems Brothers: ☐ ☐ ☐ Cancer other: ☐ ☐ HISTORY OF MEDICAL CONDITIONS Have you ever had any of the following conditions? (Check all that apply) Anemia (low iron blood) Asthma (wheezing) Diabetes (sugar) ☐ ☐ ☐ Heart Trouble Hemorrhoids (piles) Cancer ☐ ☐ ☐ Hepatitis (yellow jaundice) Tuberculosis (TB) Liver Trouble ☐ ☐ ☐ Pneumonia Rheumatic Fever Ulcers ☐ ☐ ☐ Stroke High Blood Pressure ☐ ☐ Skin problems Depression (feeling down or blue) ☐ ☐ Epilepsy (fits, seizures) Anxiety (nerves, panic attacks) ☐ ☐ VD, STD (syphilis, gonorrhea, chlamydia, HIV) ☐ Other ☐
FAMILY HISTORY What medical problems do people in your family have? Family Member Medical Problems Mother: ☐ Diabetes (sugar) ☐ High blood pressure ☐ Heart problems ☐ Cancer ☐ other: Father: ☐ Diabetes (sugar) ☐ High blood pressure ☐ Heart problems ☐ Cancer ☐ other: Sisters: ☐ Diabetes (sugar) ☐ High blood pressure ☐ Heart problems ☐ Cancer ☐ other: Brothers: ☐ Diabetes (sugar) ☐ High blood pressure ☐ Heart problems ☐ Cancer ☐ other: HISTORY OF MEDICAL CONDITIONS Have you ever had any of the following conditions? (Check all that apply) ☐ Anemia (low iron blood) ☐ Asthma (wheezing) ☐ Diabetes (sugar) ☐ Heart Trouble ☐ Hemorrhoids (piles) ☐ Cancer ☐ Hepatitis (yellow jaundice) ☐ Tuberculosis (TB) ☐ Liver Trouble ☐ Pneumonia ☐ Rheumatic Fever ☐ Ulcers ☐ Stroke ☐ High Blood Pressure ☐ Skin problems ☐ Depression (feeling down or blue) ☐ Epilepsy (fits, seizures) ☐ Anxiety (nerves, panic attacks) ☐ VD, STD (syphilis, gonorrhea, chlamydia, HIV) ☐ Other
healthlittoolkit2-tool11a.docx