edical History
1. How long has the applicant been the patient of the physician?
2. Has the applicant ever been diagnosed with or received treatment, attention, or advice from a physician or other practitioner for:
Yes No
a. Allergies
b. Anorexia/bulimia/other eating disorder
c. Appendicitis
d. Arthritis
e. Asthma
f. Bowel problems
g. Cancer
h. Diabetes
i. Epilepsy/seizures
j. Hearing loss
k. Heart disease
l. Hernia
m. Malaria
Yes No
n. Liver disease/hepatitis
o. Menstrual disorders
p. Mental disorders
q. Pneumonia
r. Rheumatic fever
s. Serious headache/migraine
t. Stomach ulcer
u. Typhoid fever
v. Urinary tract infection
w. Vertigo/dizziness
x. Visual problems
y. Eyeglasses/contact lenses