Medical Health Questionnaire – Medical History

Medical History – Questionnaire


Have you ever been told you have had any
of the following treatments, conditions or diseases?

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High blood pressure/hypertension Questions Artificial joint Questions
Kidney disease Questions Asthma Questions
Angina/chest pain Questions Sexually transmitted infection Questions
Organ/cell transplant Questions Diabetes mellitus Questions
Heart attack (myocardial infarction) Questions AIDS/HIV disease Questions
Cancer Questions Thyroid disorder Questions
Prosthetic heart valve Questions Tuberculosis Questions
Radiation therapy Questions Autoimmune disorder Questions
Irregular heartbeat (arrhythmia) Questions Psychiatric disorder Questions
Chemotherapy Questions Liver disease Questions
Pacemaker/defibrillator Questions Eating disorder Questions
Epilepsy/seizure Questions Hepatitis, Viral Questions
Congestive heart failure Questions Allergies Questions
Stomach/intestinal disorders Questions Anemia Questions
Stroke/TIA Questions Pregnancy Questions
Arthritis Questions Bleeding disorder Questions
Emphysema/bronchitis Questions Osteoporosis Questions

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