Blank Medical Report

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PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON T KNOW CHECK EACH ITEM YES NO DON T KNOW CHECK EACH ITEM Household contact with anyone with tuberculosis Shortness of breath Bone, joint or other deformity Pain or pressure in chest Loss of finger or toe Tuberculosis or positive TB test Chronic cough Blood in sputum or when coughing Palpitation or pounding heart Painful or "trick" shoulder or elbow Excessive bleeding after injury or dental work High or low blood pressure Recurrent back pain or any back injury Cramps in your legs "Trick" or locked knee Suicide attempt or plans Frequent indigestion Foot trouble Sleepwalking Stomach, liver or intestinal trouble Nerve Injury Wear corrective lenses Gall bladder trouble or gallstones Paralysis (including infantile) Eye surgery to correct vision Lack vision in either eye Jaundice or hepatitis Car, train, sea or air sickness Wear a hearing aid Broken bones Frequent trouble sleeping Stutter or stammer Adverse reaction to medication Depression or excessive worry Wear a brace or back support Skin diseases Loss of memory or amnesia Scarlet fever Tumor, growth, cyst, cancer Nervous trouble of any sort Rheumatic fever Hernia Periods of unconsciousness Swollen or painful joints Hemorrhoids or rectal disease Frequent or severe headaches Frequent or painful urination Parent/sibling with diabetes, cancer, stroke or heart disease Dizziness or fainting spells Bed wetting since age 12 X-ray or other radiation therapy Eye trouble Kidney stone or blood in urine Chemotherapy Hearing loss Sugar or albumin in urine Recurrent ear infections Sexually transmitted diseases Asbestos or toxic chemical exposure Chronic or frequent colds Recent gain or loss of weight Plate, pin or rod in any bone Severe tooth or gum trouble Eating disorder (anorexia bulimia, etc.) Easy fatigability Sinusitis Hay fever or allergic rhinitis Heart trouble Head injury Arthritis, Rheumatism, or Bursitis Asthma Thyroid trouble or goiter NSN 7540-00-181-8368 Previous

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