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    CURRENT MEDICATIONS

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    PAST MEDICAL HISTORY

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    DiabetesHigh blood pressureHigh cholesterolHypothyroidismGoiterCancerLeukemiaPsoriasisAnginaHeart problemsHeart murmurPneumoniaPulmonary embolismAsthmaEmphysemaStrokeEpilepsy(seizures)CataractsKidney diseaseKidney stonesCrohn’s diseaseColitisAnemiaJaundiceHepatitisStomach/Peptic ulcerRheumatic feverTuberculosisHIV/AIDSOther...

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    Were there problems with your birth?
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