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Special Chapter on Personal or Family Medical History
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| 1 | The following questions about your medical history are not intended to pry or embarrass but rather to share what could prove to be important to family members who may seek a genetic or familial connection to a health issue or disease. Do not answer the questions if you feel uncomfortable but answers to these questions could be important to know for your family. Are you allergic to anything, especially medications? | | 2 | What surgeries have you had? Were there any complications with the anesthetic? | | 3 | What are the medications you are currently taking? | | 4 | What type of reactions did you have with medications? | | 5 | Have you ever had pneumonia, rheumatic fever, heart disease, heart murmur, polio, meningitis, kidney infection or disease, bladder disease, anemia, jaundice, hepatitis or live disease, gallbladder disease, epilepsy, seizures, migraine headaches, tuberculosis, cancer, high or low blood pressure, nervousness, diabetes, mitral valve protapse, thyroid dysfunction, asthma, lung disease, Rh sensitization, infertility, DES exposure, eye disease, impaired eyesight, ear disease, impaired hearing, any trouble with nose, sinuses, mouth or throat, any head injury, fainting spells, convulsions, frequent or severe headaches, skin disease, chronic or frequent cough, chest pain, spitting up blood, night sweats, shortness of breath, swelling of hands, feet or ankles, varicose vain (phlebitis), indigestion, stomach trouble, ulcer, rectal bleeding, loss or urine with cough or sneeze, recreational drug use (what kind?), alcoholism, used cigarettes (for how long and how many per day?), or transfusions? |
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