Previous Illnesses

Did you ever have:
yes/no
when? 
Did you ever have: 
yes/no
when? 
Blood Transfusion 
n
High Blood Pressure 
n
Measles 
y
5 years old
Venereal Disease 
n
Mumps
y
7 years old
Kidney Disease 
n
Chickenpox 
y
10 years old
Epilepsy 
n
Scarlet Fever 
n
Anemia 
n
Rheumatic Fever 
n
Major Surgeries 
none
Diabetes 
n
Other 
arthritis
Heart Disease 
n
Other 3 months ago a cough and dull achy chest pain*.
* Records of this illness available on request
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©1998,  Neal R. Chamberlain, Ph.D.. All rights reserved.