 |
|
|
|
| Have you ever had any of
the following?: |
|
|
|
|
Arthritis |
 |
|
Hypertension |
|
|
Alcohol/substance abuse
problem |
|
|
Infectious diseases |
|
|
Asthma |
|
|
Kidney/renal disease |
|
|
Cancer |
|
|
Liver disease/hepatitis |
|
|
Cervical neck/spine problems |
|
|
Migraine disease |
|
|
Deep vein
thrombosis/phlebitis |
|
|
Psychiatric illness |
|
|
Dental problems |
|
|
Pulmonary disease |
|
|
Depression |
|
|
Seizures/epilepsy |
|
|
Diabetes |
|
|
Sinus/allergy problems |
|
|
Ear, nose & throat problems |
|
|
Skin problems |
|
|
Glaucoma |
|
|
Stroke/transient ischemic
attack |
|
|
Gynecological problems |
|
|
Thyroid disease |
|
|
Head injury |
|
|
Ulcers/gastrointestinal
problems |
|
|
Headache (tension, cluster,
other) |
|
|
Other
_________________________ |
|
|
Heart disease |
|
|
Other
_________________________ |
|
|
|
|
|
| Have you had any of the
following tests?: |
|
|
|
|
CT Scan When?
_________________ |
|
|
MRA When?
_____________________ |
|
|
MRI When?
_____________________ |
|
|
X-Rays When?
__________________ |
|
|
Lumbar Puncture When?
__________ |
|
|
Infectious diseases |
|
|
