Depression = rE>\(
Drug/alcohol abuse or misuse (see back of sheet) = 70J?$% :m,UF 6% +%G*>@$% :m,UF
Food Issues: restriction or overeating = 34a% Y%'-C%
Insomnia (problems sleeping) = sG[
Obsessive compulsive = W'Z#$% ^%0j0$%
Suicide attempt = G,J8N% <$6,J(
Anemia/bleeding disorder/hemophilia = )*$,M &'( ,="=;0@Z$% 6% ,=@=Na%
Cancer = /,m'j
Dental surgery other than wisdom teeth Diabetes = /,\ja% <t%'.
Intestinal problems (colitis, Crohn’s, irritable bowel) = u=Z8@$% /0$0#$% <(i_8( v% /0$0#$% Y,Z8$%
Kidney/bladder/recurrent UTI = <=$0K$% w$,9@$% 6% T6*Q 6% <N,`@$% 34,5( 6% I"?$% :; 34,5(
Laxative use, habitual = O="( )%*>8j%
Liver or gallbladder disease = *K?$% &%'([
Migraines = :Eb\$% D%*b$%
Passing out or loss of consciousness = V,@xe
Seizures or epilepsy = D'd 6% +,m0Ky(
Skin diseases (e.g., eczema, psoriasis) = W*". &'(
Hearing or Vision Problem (other than lenses) = <Sv'$% 34,5( 6% 2@9$% 34,5(
Stomach problems (ulcer, reflux) = (z'#$%) h*U@$% 34,5(
Thyroid or other endocrine conditions = <=LG*$% h*B$% 34,5(
Transfusion of blood/blood product = )*$% 3#N
Other = '{|
Family History = :"P,U$% RSG,8$%
Alcoholism = 70J?$% /,(}e
Cancer = /,m'j
Diabetes = W'?9$% &'(
Heart Disease = !"#$% &'(
Sudden Cardiac Death = !"#$% +0(
Hepatitis or liver disease = *K?$% &%'([ 6% *K?$% Y,Z8$%
High Blood Pressure = )*$% ABC D,EFG%
High Cholesterol = 76'89$0?$% <K9N D,EFG%
Kidney Disease = I"?$% &%'([
Other = '{%
Mental Illness/Suicide = G,J8N% 6% <="#U$% &%'([
Stroke/Blood clotting problems = <=x,(*$% <8?9$%
Thyroid problems = <=LG*$% h*B$% 34,5(
Tuberculosis = 39$% &'(