Please check any medical problems you have had: Pg 2/3
(   ) Irritable Bowel (   ) Prostate Problem (   ) Breast Cancer
(   ) Crohn's Disease (   ) Stroke/TIA (   ) Prostate Cancer
(   ) Ulcerative Colitis (   ) Depression (   ) Female Cancer
(   ) Hepatitis (   ) Nervous Breakdown (   ) Melanoma
(   ) Stomach Ulcer (   ) Migraine Headache (   ) Skin Cancer
(   ) High Blood Pressure (   ) Glaucoma (   ) Gout
(   ) Angina (   ) Anemia (   ) HIV or AIDS
(   ) Heart Attack (   ) Asthma (   ) Tuberculosis
(   ) Diabetes (   ) Kidney Disease (   ) Syphilis
(   ) Thyroid Problem (   ) Kidney Stones (   ) Herpes
(   ) Seizure or Epilepsy (   ) Hernia (   ) Eczema
(   ) Emphysema/COPD (   ) Arthritis (   ) Psoriasis
Medication Allergies: (check all that apply)
(   ) None (   ) Sulfa  (   ) IV contrast dye
(   ) Penicillin (   ) Iodine/shellfish (   ) Codeine
(   ) Other (please list): ___________________________________________________________________
Please list all medicines you are taking at this time, include off the shelf, vitamins and herbs:
Aspirin            yes     no ___________________ __________________
Motrin/Advil    yes     no ___________________ __________________
_____________________ ___________________ __________________
_____________________ ___________________ __________________
_____________________ ___________________ __________________
_____________________ ___________________ __________________
_____________________ ___________________ __________________
Check any of the operations or surgeries you have had starting from birth:
(   ) Gallbladder (   ) Appendix (   ) Hysterectomy
(   ) Colon  (   ) Thyroid (   ) Bladder
(   ) Stomach (   ) Prostate (   ) Breast
(   ) Spleen (   ) Heart (   ) Stent
Other (please list): __________________________________________________________________
Check any personal habits that apply:
(   ) Smoking #cigarettes/day______ (   ) Beer/Wine/Liquor #/week___ (   ) Marijuana
(   ) No longer smoke (   ) No longer drink (   ) Chewing Tobacco
(   ) Never smoked (   ) Never drank (   ) Cocaine
Check any illnesses known to be present in your blood relatives:
(   ) Colon Cancer (   ) Breast Cancer (   ) Diabetes
(   ) Stomach Cancer (   ) Prostate Cancer (   ) Crohn's Disease
(   ) Cervical/Uterine Cancer (   ) Bladder Cancer (   ) Ulcerative Colitis
(   ) Heart Disease (   ) Liver Disease (   ) Gallstones
(   ) Sprue/Celiac  (   ) Kidney Disease (   ) Bleeding Issues
Other (please list): __________________________________________________________________