Name: _________________________________Date: ______________Age: __________ PAST MEDICAL HISTORY YEAR ILLNESSES
________ ( ) Heart trouble (angina__) (heart attack ___) (Heart failure ___) (Heart murmur __) (valve
________ ( ) High blood pressure ________ ( ) Stroke ________ ( ) Ulcers (stomach ___) (duodenal___) (colon___) ________ ( ) Diabetes (high blood sugar) ________ ( ) Liver disease (hepatitis___) (A___) (B___) (Cirrhosis ___) Other______________________________ ________ ( ) Kidney disease (stones ___) (infections ___) other ____________ ________ ( ) Lung disease (emphysema ___)(TB___)(chronic bronchitis ___)(cancer___)
(frequent pneumonia___)(asthma___)Other_______________________
________ ( ) Blood disorders (anemia___) (leukemia ___) (bleeding tendency ___) Other _____________________________________________ ________ ( ) Eye disease (glaucoma___) Other_______________________ ________ ( ) Arthritis (degenerative___) (rheumatoid___) (gout ___)Other___________ ________ ( ) Cancer, Type ______________________________________ ________ ( ) Psychological difficulties (depression___) (psychosis ___) )Other________ ________ ( ) Other major illness_____________________________________________ ________ ( ) No major illnesses YEAR SURGERIES
________ ( ) Hysterectomy (total___) ( partial___) ________ ( ) Biopsy (result & type__________________________) ________ ( ) Fractures explain_________________________________________ ________ ( ) Other _________________________________________________
MAJOR INJURIES/ ACCIDENTES MAYORES ( ) Auto or cycle accidents:________________________________________________ ( ) NO MAJOR INJURIES HOSPITALIZATIONS:__________________________________________________
MEDICATIONS/MEDICINAS (Names & Dosages, if you have more please list on the back of the page.) ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) Birth Control Pill __________________________________________________ ALLERGIES Describe Reaction: ( ) Penicillin (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
(rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
( ) Keflex (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__) ( ) Codeine (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__) ( ) Other ________________________________________________________ ( ) None ________________________________________________________ FAMILY MEDICAL HISTORY/HISTORIA MEDICA FAMILIAR MOTHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ FATHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ SIBLINGS: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ Members of my family: (brothers, sisters, grandparents, aunts, uncles) suffer from the following: ( ) Stroke
( ) Diabetes ( ) Back problems ( ) Heart trouble
SOCIAL HISTORY/HISTORIA SOCIAL 1. Married ___, Separated ___, Divorced ___, Widow-Widower____, Single______ No. of children at home ______ No. of children away ______ 2. I work as/ am retired from______________________________________________________ 3. I drink alcohol: None____ Daily____ Socially______ Beer_____ Wine_____ “Hard drinks”_______ I drink too much_______________________________ Others think I drink too much______ 4. I smoke: None____ Cigarettes_____ Pipe________ Cigars____
I smoke_____ packs______ a day, for_____ years.
C H E S M A L S I R I WA R D H A N A , S U W I N H E WA G E , R U WA N D E S H A B A N D U , S I S I R A S I R I B A D D A N A A N D A T H U L A S U M A T H I PA L A Disasters take place around the globe on a regular basis, creating challenges for various stakeholders responsible for managing the aftermath. Large-scale disasters bring about many challenges regarding human rights, resear
Revivogen - Frequently asked Questions & Answers Q) What causes hairloss and how can Revivogen help? Androgenic Alopecia: DHT: a hormone by-product causes 95% of Hair loss. Over the years, as the hair follicles get exposed to DHT, they shed their normal hairs at a high rate and the shed hairs are replaced with thinner, shorter colorless hairs also known as miniaturized hairs or peach fuzz ha
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