PATHWAYS CHRISTIAN COUNSELING

MEDICAL HISTORY

Name:____________________________________________ Date: ____________

Age: ____________________ Height: _______________ Weight: _________

Conditions YesÖ Conditions YesÖ Conditions YesÖ

AIDS/ARC	Chronic Bronchitis	Juvenile Diabetes
Arthritis	Asthma	Heart Attack/MI
Rheumatoid Arthritis	Other Lung Disorders	Coronary Artery Disease
Osteo Arthritis	Hepatitis/Other Liver Disorders	Coronary Bypass Surgery
Back/Spinal Disorders	Congenital Disease/Defect	Congestive Heart Disease
Back/Spinal Strain	Paralysis	Pacemaker
Scoliosis	Multiple Sclerosis	Heart Disease
Spina Bifida	Cerebral Palsy	Other Heart Disease
Ulcerative Colitis	Epilepsy	Alcohol or Drug Dependency
Diverticulitis	Parkinson’s Disease	Attempted Suicide
Crohn’s Disease	Alzheimer’s Disease or Dementia	Anorexia/Bulemia
Gastric/Peptic Ulcer	Other Neurological Disorder	Chronic Depression
Other Bowel/Stomach Disorders	Hemophilia	Other Mental/Emotional Disorders
Stroke (date)	Kidney/Urinary Disorders	Sexually Transmitted Disease
Cancer (type)	Tumors/Growths	Deafness
Emphysema	Diabetes Mellitus (give 3 blood sugars with dates)	High Blood Pressure (give last 3 pressures with dates)

Please list any other serious medical conditions you may have experienced (i.e. automobile accidents or surgeries – including date, description of event and length of treatment) and medications (including name, dosage, and length of time taken):

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