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Personal Health History: Please check box with an X if your answer is Yes, leave blank if the answer is No _____ Recurrent Headache _____ Pain/Pressure in Chest _____ Anemia _____ Head injury w/unconsciousness _____ High or Low Blood Pressure _____ Kidney Disease _____ Penicillin _____ Epilepsy, Convulsions _____ Rheumatic Fever _____ Urinary Infection _____ Sulfa Drugs _____ Dizziness, Fainting _____ Heart Murmur _____ Arthritis _____ Serum, Vaccines _____ Migraines _____ Diabetes _____ Trick knee/shoulder _____ Foods _____ Sinusitis _____ Stomach or Intestinal Trouble _____ Back Problems _____ Other _____ Gum or tooth trouble _____ Gallbladder or Gallstones _____ Weakness, Paralysis _____ Eye trouble (vision) _____ Recurrent Diarrhea _____ Skin Disease _____ Recurrent Colds _____ Jaundice _____ Insomnia _____ Hay Fever _____ Hepatitis _____ Frequent Depression _____ Tuberculosis _____ Tumor, cancer or cyst _____ Worry or nervousness _____ Shortness of breach _____ Rupture/hernia _____ Chronic Cough _____ Recent weight gain or loss _____ Palpitations (heart) _____ Thyroid Disease Surgery: __________________ _____ Appendectomy _____ Tonsillectomy _________________ Allergies: _____ Penicillin _____ Sulfa Drugs _____ Serum, Vaccines _____ Foods _____ Other __________________ Please list any prescribed or over the counter medication used regularly: __________________ __________________ _________________ _________________ _________________ |