Health Record

I do not know the medical history of my biological parents or other family members.

Unknown

Mother's current age

If deceased, age of death

If deceased, cause of death

Unknown

Father's current age

If deceased, age of death

If deceased, cause of death

Unknown

Number living

Number deceased

Cause(s) of death(s)

Question	Yes	No
General
Recent weight loss of more than 10 lbs?
Recent weight gain of more than 10 lbs?
Fever?
Chills?
Night sweats?
Have you seen your primary care physician in the past year?
Respiratory
Wheezing?
Pnuemonia?
Chronic Cough?
Skin
Open sores?
New moles?
Poor healing?
Skin Infection?
Gastrointestinal
Abdominal pain?
Diarrhea?
Liver problems?
Nausea?
Vomiting?

Do you have allergies?**

Yes

No (No known drug allergies)