Clymer Healing Center	Woodlands Healing Research Center
5916 Clymer Rd., Quakertown, PA 18951 * 215-536-8001 * Fax 215-536-9099	5724 Clymer Rd., Quakertown, PA 18951 * 215-536-1890 * Fax 215-529-9034

ADULT HEALTH HISTORY QUESTIONNAIRE

(Ages: 13+ yrs old)

Click here to Return to New Patient Information Page

MEDICATION ALLERGY AND INTOLERANCE: List any medication or supplement you are allergic to or which caused unpleasant side effects; include the name of the substance, the age it occurred, how it was taken (mouth, vein, etc), what reaction occurred, and the treatment if given. Use additional sheets if necessary.

Prescription Medication	Date	Route given	Reaction	Any Treatment Given
Example: Penicillin	02/2002	By mouth	Hives, breathing difficulty	None

MEDICATIONS: List medicines, both prescribed by a physician and obtained without a prescription (those that you can buy on your own), that you are currently taking or have taken recently. Complete as much as you are able. Including the name of the medicine, the strength of the medicine (dosage), how often you take it (frequency), date started and date stopped if you are no longer are using it. Please bring all your medication to your appointment. Use the other side of this sheet or additional sheets if necessary.

Medication	Dose	Frequency (times per day)	Started	Stopped
Example: Benadryl	25mg	1 pill 2 times per day	1990	---------

VITAMINS, MINERALS, AND OTHER NUTRITIONAL SUPPLEMENTS:

As above, please list your nutritional supplements to include vitamins, minerals, herbs, homeopathic remedies, folk remedies, and other nutritional or alternative therapies. Please include the form of the supplement (pill/liquid, etc), and the dosage (mg, IU, etc). Please bring all your supplements to your appointment. Use the other side of this sheet or additional sheets if necessary.

Vitamin/Herb/Supplement	Dose	Frequency (times per day)	Started	Stopped
Example: Vitamin C	500mg	1 pill 3 times per day	06/01/2000	---------

Antibiotics: List the number of times you have been on antibiotics such as Penicillin, Tetracycline, Amoxicillin, Keflex, Ceclor, Erythromycin, or other antibiotics: NO YES, The number of times given antibiotics:

Please check any of the reasons listed as to why you were prescribed antibiotics, include as many as apply:

Acne/skin condition Colds Tonsillitis/Strep Throat Ear Infection(s) Bladder/Kidney Infection

Other:

Steroids: Have you ever taken an oral cortisone preparation such as Prednisone, Decadron, Medrol, or others? If yes, state how many times. NO YES, The number of times given steroid pills:

Have you received a cortisone type "shot" such a Depo Medrol, Decadron, Kenalog, or others?

NO YES, The number of times given steroid injections:

Home/School Environment: Complete the following to the best of your knowledge. Skip if unknown
Home Environment
Pets:	Dog(s)	Cat(s)	Other:
Do you live in a:	Single house	Apartment	Mobile Home	Other:

Age of the house/place you live:

How long have you lived there?

What part of your residence do you feel best?	Feel the worst?
In which part of the house do you spend the most time?

	Ozone Generator	Ionizer	Other:

Other:

Use Air Fresheners

Use Mothballs

Use fluoridated toothpaste

Termite Treatment:	No Yes	Chemical Name:
Pesticide Use:	No Yes	Chemical Name:
Lawn Sprays:	No Yes	Chemical Name:

Work Environment:
At work my symptoms are: Worse	Better	Same/No Change

Is there any particular place or room at work which bothers you or aggravates your symptoms?
Has the air quality in your work been a concern to your or others?, Explain:

Allergy Testing & Treatments: Complete if you have every had any allergy tests or treatments
1. Have you ever had allergy testing for Airborne Inhalants (dust, molds, grasses, trees, weeds, etc) No Yes
What type?	Prick (the skin is just "poked")	Scratch		Intradermal (injection by needle into skin	Blood
Other:
When (Date)?			Doctor's Name:

2. Have you ever had allergy testing for Food Allergy? No Yes
What type?	Prick (the skin is just "poked")	Scratch	Intradermal (injection by needle into skin	Blood

Elimination/Rechallenge Diet

Sublingual (Under tongue)

Other:

When (Date)?			Doctor's Name:
3. Are you now or have you in the past taken Allergy Shots?No Yes, in past from to
I am presently taking allergy shots, I started my first dose
I receive my shots:	2+ times per week	Once per week		Every 2 weeks	Monthly	Seasonally as needed

Any improvements/benefits with the shots?	Yes	No	Don't know
Any reactions to the shots?	Yes	No	Don't know

4. Are you now or have you in the past taken Allergy Drops?NoYes, in past from to
I am presently taking allergy drops, I started my first dose
I receive my drops:	times/day	Other:

Any improvements/benefits with the drops?	Yes	No	Don't know
Any reactions to the drops?	Yes	No	Don't know
5. Other Allergy Treatments: Elimination/Rotary DietsNAET Other:

PAST MEDICAL HISTORY: Answer to the best of your ability, any question you don't know, just leave blank.

List any other past or present illnesses:


If you were ever hospitalized for at least one overnight stay (but did NOT involve surgery or child birth), please describe:

OPERATIONS/SURGERIES: Please list your major operations, including same day surgery. List the name of operation, date it occurred, your age, the reason for the operation, name of the hospital, city and state, and any complications (include any anesthesia reactions). Start with early childhood and list in order to the most recent:
Operation	Date	Age	Reason/Complication	Hospital
Ex: Tonsillectomy	02/20/1962	5	Recurrent sore throats	Shriners Hospital

INJURIES: List any past injuries you have had (not including those stated in the current problem section). Include the type of injury (car accident, fall, broken bones, machinery/occupation accident, etc), the date it occurred, your age, and any treatment given. Please list from oldest injury to most recent:
Injury	Date	Age	How Injury Occurred	Treatment Given
Ex: Neck Sprain	02/20/1962	20	Car Accident	Chiropractic

HEALTH CARE MAINTENANCE: Please list when you last had the following tests, date, age, location, and the result if known:
Test	Date	Result
Physical Exam
Rectal Exam
Stool for Blood
Colonoscopy
Sigmoidoscopy
Cholesterol
Eye Exam/Vision Test
Hearing Test
Dental Exam
For Women:	Do you perform regular (monthly) self-breast exams? Yes No
Breast Exam by Doctor
Mammogram
PAP Smear/Pelvic Exam
For Men:	Do you perform regular (monthly) selft-testicle exams? Yes No
Prostate/Testicle Exam
PSA Blood Test

IMMUNIZATIONS: Please list the date and age of any immunization or vaccine you have received and any reaction you may have had (you may bring list on separate sheet from another’s physician’s office if available):
Immunization	Date	Reaction	Immunization	Date	Reaction
DTaP#1			MMR#1
DTaP#2			MMR#2
DTaP#3			PCV (Pneumococcal)#1
DTaP#4			PCV (Pneumococcal)#2
DTaP#5			PCV (Pneumococcal)#3
TetanusBooster (DT)			PCV (Pneumococcal)#4
Hib (H.flu)#1			Chickenpox#1
Hib (H.flu)#2			Chickenpox#2
Hib (H.flu)#3			Meningococcal
Hib (H.flu)#4			Last Flu shot
Hepatitis B#1			Last Tetanus shot
Hepatitis B#2			Last Pneumonia shot
Hepatitis B#3			Tuberculosis (TB) Test
Polio#1			Other
Polio#2
Polio#3
Polio#4

CHIEF COMPLAINT: In your own words, what are your main complaints? State the nature and duration of the symptoms:

Severity (of chief complaint): Mild Mild to Moderate Moderate Moderate to Severe Severe
Interferes with my life, how?:
I am on disability:Social Security Disability (SSD) Private Plan; Date Awarded:
Please list handicaps/disabilities:
Antecedents: When was the last time you were well? What happened after that time?

During the 12 months preceding the onset of your present condition(s), check those that apply and briefly comment:
Was under severe stress:
Moved to new residence or home:
Traveled outside the U.S.:
Involved in wilderness activity:
Experienced an injury:
Experienced fever or acute illness:
Took drugs or medications:
Had chemical or toxic exposure:

REVIEW OF SYMPTOMS: Check the symptoms that apply to you. Note whether the symptom is past, now or both:
General:
Past Now Tired without effort	Past Now Fever	Past Now Flu like symptoms
Past Now Chills	Past Now Night sweat	Past Now Cold intolerance
Past Now Heat Intolerance	Past Now Weight Gain: lbs	Past Now Weight Loss: lbs
Neurological:	Past Now Attention Difficulties	Past Now Concentration prob's
Past Now Can't Decide easily	Past Now Thinking Difficulties	Past Now Poor memory (long term)
Past Now Poor Memory (short term)	Past Now Disorientation	Past Now Hyperactivity
Past Now Constant Movement	Past Now Low Activity (Hypo)
Past Now Sleep too much	Past Now Difficulty falling asleep	Past Now Frequent awakening
Past Now Nightmares	Past Now Restless Legs	Past Now Un-refreshed Sleep
Past Now Dizziness	Past Now Fainting/Blacking out	Past Now Convulsions/Seizure
Past Now Speech problem	Past Now Burning sensations	Past Now Electrical Zaps
Past Now Numbness	Past Now Tingling	Past Now Headaches
Past Now Weakness	Past Now Clumsiness	Past Now Tremors
Past Now Repeats same action(s)	Past Now Head Banging	Past Now Rocking
Past Now Picking	Past Now "Pill rolling" actions	Past Now Paralysis
Mental/Emotional:
Past Now Anxiety/Nerves on edge	Past Now Apprehension	Past Now Fearful
Past Now Fearful of going out	Past Now Other Specific Fear:
Past Now Panic Episodes	Past Now Flashback memories:
Past Now Sad/Depressed mood	Past Now Hopelessness	Past Now Guilt
Past Now Lost of interest in life	Past Now Suicidal Thoughts	Past Now Suicidal Attempt(s)
Past Now Angry	Past Now Irritable	Past Now Mood Swings
Past Now Jekyll/Hyde personality	Past Now Stress @ work	Past Now Stress @ home
PastNow Stress in a Relationship:	Explain:
What are your other major stressors?
Past Now Anorexia	Past Now Binge eating	Past Now Impulsive eating
Past Now Purging	Past Now Sugar cravings	Past Now Anti-social behaviors
Past Now Compulsive behaviors	Past Now Obsessive behaviors	Past Now Defiant behavior
Past Now Temper Tantrums	Past Now Hallucinations	Past Now Manic Episodes
Eye(s):	Past Now Vision Loss	Past Now Vision Change
Past Now Blurry Vision	Past Now Spots/floaters	Past Now Wear Glasses
Past Now Wear Contact Lenses	Past Now Pain in eye(s)	Past Now Red eye(s)
Past Now Dryness	Past Now Light sensitivity	Past Now Swelling of eye(s)
Past Now Itchy eye(s)	Past Now Watery/Teary
Past Now Cataract(s)	Past Now Glaucoma	Past Now Infection
Head/Neck:	Past Now Head tenderness	Past Now Jaw pain
Past Now Neck stiffness	Past Now Neck tenderness	Past Now Swelling
Past Now Swollen glands	Past Now Lump(s)
Ears:	Past Now Recurrent Infections	Past Now Drainage/discharge
Past Now Earaches	Past Now Hearing Loss	Past Now Wear Hearing Aid
Past Now Itching	Past Now Noise Sensitivity	Past Now Tinnitus
Past Now Vertigo	Past Now Redness
Nose:	Past Now Frequent Colds	Past Now Congestion
Past Now Runny nose	Past Now Post Nasal Drip	Past Now Nose blockage
Past Now Itching	Past Now Sneezing	Past Now Nose Bleeds
Past Now Snoring	Past Now Facial Pain	Past Now Sinus Pain
Mouth/Throat:	Past Now Cracked Lips	Past Now Sore Lips
Past Now Dry Mouth	Past Now Sores in mouth	Past Now Ulcers in mouth
Past Now Bad Breath	Past Now Coated Tongue	Past Now Abnormal Taste
Past Now Metallic Taste	Past Now Gum Problems	Past Now Bleeding Gums
Past Now Toothache	Past Now Loose/Missing Teeth	Past Now Grinding of teeth
Past Now Chewing difficulty	Past Now Silver (metal) Fillings	Past Now Dentures
Past Now Sore Throats-frequent	Past Now Swollen Tonsils	Past Now Hoarseness
Respiratory/Lungs:	Past Now Short of Breath @ rest	Past Now Short of Breath-exertion
Past Now Short of Breath-lying	Past Now Wheezing	Past Now Cough-occasional
Past Now Cough-all the time	Past Now Cough- dry	Past Now Cough- phlegm
Past Now Cough with blood
Cardio-Vascular/Heart:	Past Now Chest Pain @ rest	Past Now Chest Pain-exertion
Past Now Chest Pressure	Past Now Fast Heart Rate	Past Now Slow Heart Rate
Past Now Palpitations	Past Now Coldness of hands/feet	Past Now Blue hands/feet
Past Now Fingertips discolored	Past Now Fingertips white	Past Now Leg pain when walking
Past Now Swelling feet/legs	Past Now Ulcers of feet/legs	Past Now Varicose veins
Past Now Blood Pressure Low	Past Now Blood Pressure High
Digestive/Gastro-Intestinal:	Past Now Change of Appetite	Past Now Eats Dirt/Paint/Plaster
Past Now Ravenous Appetite	Past Now Poor/Loss of Appetite	Past Now On a Weight Loss Diet
Past Now Difficulty Chewing	Past Now Difficulty/Pain Swallowing	Past Now Stomach fills up quickly
Past Now Indigestion	Past Now Use Anti-acids	Past Now Belching
Past Now Reflux	Past Now Nausea	Past Now Vomiting
Past Now Vomiting Blood	Past Now Vomiting-projectile	Past Now Abdominal Lump/Mass
Past Now Abdominal Bloating	Past Now Abdominal Distension	Past Now Abdominal Pain
Past Now Distress from eating	Past Now Hernia	Past Now Yellow Jaundice
Food Intolerances: Please list past and/or present food triggered symptoms (any symptoms).

	Food	Symptom(s)		Food	Symptom(s)
Past Now			Past Now
	Food	Symptom(s)		Food	Symptom(s)
Past Now			Past Now
Past Now			Past Now

Past Now Colitis	Past Now Gas/Flatus-excessive	Past Now Constipation
Past Now Uses Laxatives	Past Now Diarrhea	Past Now Can't control bowels
Past Now Change in bowel habits	Past Now Abnormal Stools	Past Now Blood in stools
Past Now Black/Tar-like stools	Past Now Undigested food in stool	Past Now Rectal Fissue
Past Now Rectal Fistula	Past Now Hemorrhoids	Past Now Rectal Pain
Past Now Rectal Itching
Urinary:	Past Now Bed Wetting	Past Now Bladder Pain
Past Now Recurrent Ur Infections	Past Now Urine Dribbling	Past Now Painful Urination
Past Now Urine Urgency	Past Now Urine Frequency	Past Now Wake Up to Urinate
Past Now Slow Stream	Past Now Loss of Urine	Past Now Urinate very little
Past Now Urinate a lot	Past Now Blood in Urine	Past Now Cloudy Urine
Past Now Dark Urine	Past Now Red Urine	Past Now Tea Colored Urine
Female:	Past Now Breast Feeding	Past Now Breast Lump
Past Now Nipple Discharge	Past Now Breast Pain/Tenderness
Past Now Sexually Active	Past Now Abstinent	Past Now Decreased sex desire
Past Now Infertility	Past Now Pelvic Pain	Past Now Pain with intercourse
Past Now Genital Rash	Past Now Genital Lesions	Past Now Vaginal Discharge
Past Now Vaginal Itch	Past Now Vaginal Odor	Past Now Vaginal Pain
Past Now Bleeding between cycles	Past Now Irregular Bleeding	Past Now Mid Cycle Pain
Past Now Premenstrual Symptoms:
Past Now Heavy Menses	Past Now Menstrual Pain	Past Now Menstrual Headache
Past Now Too Frequent Menses	Past Now Infrequent Menses	Past Now No Menses
Menses onset @ age: ; Cycle every days; Lasting for days
Menopause @ age:	Past Now Menopause Symptoms:
Past Now Post Menopause bleeding
Male:	Past Now Genital Lesions	Past Now Scrotal Rash/Lesions
Past Now Penile Rash/Lesions	Past Now Penile Discharge	Past Now Testicle Pain
Past Now Infertility	Past Now Prostate Problem	Past Now Sexually Active
Past Now Abstinent	Past Now Decreased Sex Desire	Past Now Poor Erection
Past Now Impotent/no erection	Past Now Pain with Ejaculation	Past Now Premature Ejaculation
Past Now No Ejaculation	Past Now Ejaculation while asleep	Past Now Pain with Intercourse
Musculo-Skeletal:	Past Now General Aches	Past Now Artificial Joint(s)
Past Now Muscle loss (atrophy)	Past Now Bone Pain	Past Now Limited Motion
Past Now Morning Stiffness	Past Now Muscle Pain	Past Now Muscle Spasms
Past Now Muscle Weakness	Past Now Muscle Twitches	Past Now Joints Hurt/Painful
Past Now Joints Stiff	Past Now Joints Red	Past Now Joint Swelling
Past Now Neck Pain	Past Now Mid Back Pain	Past Now Low Back Pain
Past Now Sciatica	Past Now Arm Pain	Past Now Arm Swelling
Past Now Hand Pain	Past Now Hand Swelling	Past Now Leg Pain
Past Now Leg Cramps	Past Now Feet Pain	Past Now Feet Burning
Past Now Feet Cramps	Past Now Feet Swelling	Past Now Flat Feet
Past Now Difficulty with Walking
Skin/Nails/Hair:	Past Now Rashes	Past Now Eczema
Past Now Excessive Dry Skin	Past Now Itchy	Past Now Excessive Sweating
Past Now Redness	Past Now Scar(s)	Past Now Unusual Texture
Past Now Cracking	Past Now Scaling	Past Now Moles
Past Now Moles Changing	Past Now Increase skin pigment	Past Now Loss skin pigment
Past Now Acne	Past Now Skin Cancer	Past Now Hives
Past Now Warts	Past Now Skin Ulcers
Past Now Brittle Nails	Past Now Thickened Nails	Past Now Discolored Nails
Past Now Pitted Nails	Past Now Inflamed Cuticles	Past Now Ingrown Nail
Past Now Fungal Infection Nails	Past Now Blue Nails	Past Now "Spoon" Shaped Nails
Past Now Dry Hair	Past Now Brittle Hair	Past Now Oily Hair
Past Now Dandruff	Past Now Scalp Itch	Past Now Hair Loss
Past Now Increased Hair Growth	Past Now Processes/Dye Hair
Endocrine:	Past Now Rapid Growth	Past Now Slow Growth
Past Now Overweight	Past Now Underweight	Past Now Can't Gain Weight
Past Now Can't Lose Weight	Past Now Thyroid Goiter	Past Now Hot Flashes
Past Now Too Thirsty	Past Now No Thirst	Past Now Drink alot
Blood & Lymph:	Past Now Easy Bleeding	Past Now Prolonged Bleeding
Past Now Blood Clot	Past Now Easy Bruising	Past Now Frequent Bruising
Past Now Lymph Node Swelling
Allergy & Environmental: Check those symptoms affected by the following environmental patterns:

Pattern	Nose	Eye	Lung	Skin	Other Body Symptom
Worse indoors
Improved outdoors
Increased symptoms within 30min of going to bed
Symptoms recur/increase with cold weather
Worse in air conditioning
Worse dusting/sweeping (dust exposure)
Worse outdoors from 4:40-8:30 PM
Worse in cool evening air
Worse damp places
Worse basements
Worse with mold/mildew exposure
Worse raking or exposure to leaves
Worse Sept to heavy/killing frost
Worse outdoors 7-11:00 AM
Improved indoors, esp with air conditioning
Improved with rain
Worse exposure to feed mills
Worse in barns
Worse after exposure to cats
Worse after exposure to dogs
Worse exposure to other animal:
Worse exposure to other animal:
Pattern	Nose	Eye	Lung	Skin	Other Body Symptom
Insect Reaction, (name insect(s)):
Worse with/after exercise
Worse when hot or overheated
Worse with cold exposure
Present or worse winter
Present or worse spring
Present or worse summer
Present or worse fall
Present all year (all the time)
Worse with storm fronts
Worse with wind
Worse on rainy day
Worse on dry day
Worse with high humidity
Worse from the following Chemical Exposure:	Nose	Eye	Lung	Skin	Other Body Symptom
Gasoline Products
Exhaust Fumes
Asphalt, Tar
Polishes, Floor Waxes
Moth Balls
Varnish, Paint, Shellac
New Cars
Latex Gloves
Soaps/Detergents
Chlorinated Water
Ammonia
Bleach
Household Cleaners
Disinfectants
Cosmetics
Hair Spray
Perfumes
Air Fresheners
Newsprint
Tobacco Smoke
Metals/Jewelry
Insect Sprays
Rubber Products
Other Chemical(s):

Live on a farm	In a wooded area	Near a swamp	Near Stream	City
Suburbs	Near chemical factory/smoke stack	Heavy traffic	Near power lines/transformers
Did your medical symptoms or problems begin after moving into your current residence?			Yes No Don't know
Are your symptoms better when you are away from your current residence?			Yes No Don't know

Is the Garage:	Attached	Detached	Breezeway	Underneath
Is the Basement:	Dry	Damp	Musty	Flooded in past	Can see mold
Is the Insulation:	Fiberglass	Cellulose	Sawdust	Styrofoam	Urea foam
Are the Carpets:	Wall to Wall	Area rugs	Cotton	Wool	Synthetic
Is the Heat:	Electric	Gas	Oil	Solar
	Forced Hot Air	Coal	Space Heater	Wood Burning Stove
Hot Water Heater:	Electric	Gas	Oil	Solar
Air Conditioner:	Central Air	Room Units
Humidifier:	On furnace	Room Unit		Dehumidifier
Is the Stove:	Gas	Electric	Is the Dryer:	Gas	Electric
Air Purifier:	Central Unit	Room Units
Are the filters:	HEPA	Charcoal	UV lights	Fiberglass	Electrostatic

Past Illnesses: Check the disease or conditions that apply to you. Please note whether the problem is now, past or both:
Past Now Birth Defects	Past Now Genetic Illness
Past Now Chicken Pox	Past Now Croup	Past Now Measles
Past Now Measles	Past Now German Measles	Past Now Polio
Past Now Rheumatic Fever	Past Now Scarlet Fever	Past Now Whooping Cough
Past Now Mono (EBV)	Past Now CMV Virus	Past Now Coxsackie Virus
Past Now HIV Virus (AIDS)	Past Now Lyme Disease	Past Now Meningitis
Past Now Attention Deficit	Past Now Hyperactivity	Past Now Learning Problem
Past Now Dyslexia	Past Now Developmental Delay	Past Now Depression
Past Now Tension/Anxiety Problem	Past Now Post Traumatic Stress	Past Now Physical Abuse
Past Now Sexual Abuse	Past Now Anorexia	Past Now Bulimia
Past Now Migraine Headache	Past Now Epilepsy (Seizures)
Past Now Nearsighted	Past Now Farsighted	Past Now Wears Glasses
Past Now Lazy Eye	Past Now Blindness
Past Now Deafness	Past Now Wears Hearing Aid	Past Now Recurrent Ear Infections
Past Now Hayfever/Allergy	Past Now Recurrent Sinus Infection	Past Now Nose Polyps
Past Now Dental Problems	Past Now Mouth Ulcers/Sores	Past Now Recurrent Tonsillitis
Past Now Congenital Heart Disease	Past Now Heart Rhythm Problems	Past Now Heart Murmur
Past Now Mitral Valve Prolapse	Past Now Other Heart Valve Problem
Past Now Asthma	Past Now Recurrent Bronchitis	Past Now Pneumonia
Past Now Tuberculosis
Past Now Acid Reflux Stomach	Past Now Stomach Ulcer	Past Now Lactose Intolerance
Past Now Colitis	Past Now Crohn's Disease	Past Now Celiac Disease
Past Now Irritable (Spastic) Bowel	Past Now Jaundice	Past Now Hernia
Past Now Hepatitis A	Past Now Hepatitis B	Past Now Hepatitis C
Past Now Dysentery	Past Now Parasites	Past Now Giardia
Past Now Candida	Past Now Worms
Past Now Bladder Infection	Past Now Kidney Infection	Past Now Urethral Stricture
Past Now Vaginitis (Yeast)	Past Now Vaginitis (Other)	Past Now Venereal Disease (VD)
Past Now Muscular Dystrophy	Past Now Rheumatoid Arthritis	Past Now Lupus (SLE)
Past Now Bone Disease	Past Now Sciatica	Past Now Whiplash
Past Now Eczema	Past Now Atopic Dermatitis	Past Now Acne
Past Now Psoriasis	Past Now Seborrhea	Past Now Athletes Foot
Past Now Ringworm
Past Now Diabetes	Past Now Hypoglycemia	Past Now Weight Problem
Past Now Hyperthyroidism (High)	Past Now Hypothyroidism (Low)	Past Now Adrenal Problem
Past Now Blood Disease	Past Now Anemia	Past Now Sickle Cell Disease
Past Now Thalassemia	Past Now Hemophilia	Past Now Blood Transfusion
Past Now Immune Deficiency	Past Now Leukemia	Past Now Lymphoma
Past Now Cancer or Tumor

OBSTETRICAL/BIRTHING HISTORY: For women, starting with your first pregnancy, please list the date of the birth, how many weeks pregnant you were (ex, full term, 3 weeks early/late), any complications while you were pregnant, the type of delivery (normal vaginal birth, c-section, forceps, vacuum), sex of the baby, weight of the baby, complications of the delivery (ex, needed pitocin, epidural, bleeding problems, shoulder got stuck, baby was in distress), name of the hospital (list home if home birth). For miscarriages/abortions, list the year and how many weeks pregnant you were and any complications:
Date	Wks Preg	Pregnancy Complications	Type	Sex	Weight	Complications of Delivery	Location