Previous Illness


Did you ever have:
yes/no
when?
Did you ever have:
yes/no
when?
Blood Transfusion
n

High Blood Pressure
n

Measles
y
childhood
Venereal Disease


Mumps
y
childhood
Kidney Disease
n

Chickenpox
y
childhood
Epilepsy
n

Scarlet Fever
scarletina?
childhood?
Anemia
y
3 months ago
Rheumatic Fever
n

Major Surgeries
tonsils
age 8
Diabetes
n

Other
HIV+*
6 years ago
Heart Disease
n

Other
Pneumonia (PCP)
3 years ago

*Referral history from Dr. Awad states that the CD4+ cell count was 30/ul last month.


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