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
©1998,
Neal R. Chamberlain, Ph.D..
All rights reserved.