Check all that apply: Please explain all in the section below.

___ Chicken Pox	___ Back Problems	___ Syncope with exercise
___ German Measles	___ Musculo-skeletal Disorders	___ Kidney Infection
___ Measles	___ Neurological Disorders	___ Kidney Stones
___ Infectious Mononucleosis	___ Seizures Disorders	___ Chronic Kidney Disease
___ Rheumatic Fever	___ Fainting/Dizziness	___ Sexually Transmitted Disease
___ Scarlet Fever	___ Head Injury w/LOC	___ Blood in Urine
___ Anemia	___ Concussion	___ Protein in Urine
___ Bleeding Tendency	___ Heart Conditions	___ Sugar in Urine
___ Changes in Appetite	___ Marfan's Syndrome	___ Pelvic/Vaginal Infection
___ Changes in Weight	___ Congenital	___ Hernia
___ Anorexia Nervosa	___ Murmur	___ Menstrual History
___ Bulimia	___ Rheumatic Heart	___ Painful Periods
___ Drug/Alcohol Abuse	___ Disease	___ Heavy Flow
___ Steroid Use	___ Palpitations	___ Irregular Periods
___ Constipation	___ Other -- Specify _______________	___ Age of First Period
___ Diarrhea	___ High Blood Pressure	___ Warts, Moles, Rashes
___ Ulcerative Colitis	___ Low Blood Pressure	___ Eczema
___ Irritable Bowl Syndrome	___ Chest Pain	___ Hives
___ Crohn's Disease	___ High Cholesterol	___ Acne
___ Stomach/Intestinal Problems	___ Asthma	___ Cancer -- Type ____________
___ Jaundice/Liver Disease	___ Hay Fever	___ Diabetes Mellitus
___ Gall Bladder Trouble	___ Pneumonia	___ Hepatitis
___ Pancreatitis	___ Tuberculosis	___ Recurrent Headaches
___ Emotional Illness	___ Bronchitis	___ Migraine Headaches
___ Depression	___ Ear Infections	___ Connective Tissue Disorders
___ Insomnia	___ Cystic Fibrosis	___ Immune Deficiency Disorder
___ panic/Anxiety Attack	___ Sinusitis	___ Gum or Tooth Disorders
___ Joint Disease	___ Bladder Infection	___ Hearing Impairment
___ Bone Fractures	___ Shortness of Breath with exercise	___ Speech Impediment
___ Joint Injury	___ Pregnancy	___ Heat Related Illness
___ Vision Problems	___ Serious Accident/Injury	___ Other: Explain Below

Explanations: _________________________________________________________________________________________

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