Health Check Form

  • Arthritis:
    Yes
    No
  • Cancer:
    Yes
    No
  • Gout:
    Yes
    No
  • Diabetes:
    Yes
    No
  • Emotional Disorder:
    Yes
    No
  • Epilepsy Seizures:
    Yes
    No
  • Fainting Spells:
    Yes
    No
  • Gallbladder Disease:
    Yes
    No
  • Heart Attack History:
    Yes
    No
  • HIV:
    Yes
    No
  • Rheumatic Fever:
    Yes
    No
  • High Blood Pressure:
    Yes
    No
  • Digestive Problems:
    Yes
    No
  • Ulcerative Colitis:
    Yes
    No
  • Ulcer Disease:
    Yes
    No
  • Hepatitis:
    Yes
    No
  • Kidney Disease:
    Yes
    No
  • Liver Disease:
    Yes
    No
  • Sleep Apnea:
    Yes
    No
  • Tuberculosis:
    Yes
    No
  • Venereal Disease:
    Yes
    No
  • Neurological Disorders:
    Yes
    No
  • Bleeding Disorders:
    Yes
    No
  • Lung Disease:
    Yes
    No
  • Drug Use:
    Yes
    No
  • Drug allergies/adverse drug reaction:
    Yes
    No
  • Emphysema/Asthma:
    Yes
    No
  • Reaction to Anaesthesia:
    Yes
    No
  • Hereditary health concerns:
    Yes
    No
  • Sexually Transmitted Disease:
    Yes
    No
  • Breast Feeding:
    Yes
    No
  • Blood Transfusion:
    Yes
    No
  • Cholesterol:
    Yes
    No
  • Anemia:
    Yes
    No
  • Swollen Glands:
    Yes
    No
  • Anxiety:
    Yes
    No
  • Joint Pain:
    Yes
    No
  • Constipation or Diarrhea:
    Yes
    No
  • Abnormal Vaginal Bleeding:
    Yes
    No
  • Pelvic Pain:
    Yes
    No
  • Reflux:
    Yes
    No
  • Chest Pain:
    Yes
    No
  • Rectal Bleeding:
    Yes
    No
  • Nausea:
    Yes
    No
  • Dizziness:
    Yes
    No
  • Burning w/Urination:
    Yes
    No
  • Hot Flashes:
    Yes
    No
  • Cardiac Failure:
    Yes
    No
  • Rhythm Disturbances:
    Yes
    No
  • .

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