Medical History Questions

Family Name:___________________________ Given Name(s):_____________________________________

Check off “Yes” or “No” to the following questions. Provide details to “YES” answers. These questions apply
to your whole life.

Question Yes No Details:

1. Have you ever been diagnosed or treated for

Tuberculosis (TB)?

2. Have you ever had any close household or

work contact with anyone with Tuberculosis?

3. Have you had any operation/surgery in your

whole life? Have you ever had prolonged
medical treatment or hospital admissions for any
reason? (Includes any major operation)

4. Do you have or have you ever had a

psychological/psychiatric disorder? (Includes
major depression, bipolar disorder or
schizophrenia)

5. Have you ever had a positive HIV blood test?

6. Have you ever had a positive Hepatitis B or

C or Syphilis blood test?

7. Have you been diagnosed with cancer or any

form of malignancy in the last 5 years?

8. Have you been diagnosed with Diabetes?

(Type I or Type II)

9. Do you have any heart conditions (Includes

high blood pressure, coronary disease,
HEART valve or congenital disease)

10. Have you been diagnosed with any blood

conditions? (Includes thalassemia)

11. Have you any kidney or bladder

conditions?

12. Do you have an ongoing physical or

intellectual disability affecting your current or
future ability to function independently or be
able to work full time? (includes autism or
developmental delay)

13. Do you have an addiction to any drugs or

alcohol?
14. Are you taking any prescribed pills or
medication ?( NOT including birth control, OTC
medications or natural supplements).STATE
NAME/DOSE OF DRUG(S) need name of drug
and dose.

For FEMALE clients only: are you currently If yes, expected date of delivery:
pregnant?