My Account Personal Medical Records iDiagnosis Personal Medical History Past iOutputs     You Personal Medical History   Sex: Male Female Name: Age: Requiring a digital! Age Required! Blood Type: A B AB O Height:digital! feet  inches  Requiring a digital!  Requiring a Weight: pound Requiring a digital! Ethnicity: Select Ethnicity Asian White Hispanic Black Blood Pressure: Select Blood Pressure High Blood Pressure Normal Blood Pressure Low Blood Pressure Pulse Rate: Select Pulse Rate 50-55 55-60 60-70 70-80 80-90 Address: Email: Email format error! Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? Yes No If yes, list: Do you take any prescribed medication on a permanent or semi-permanent basis (steroids, anti-inflammatories, antibiotics, insulin, etc.)? Yes No If yes, list and give reason: Do you smoke cigarettes? Smoker Non-Smoker If yes, how many packs per day: Do you drink more than 7 bottles of beer (or equivalent) per day? Alchoholic Non-Alchoholic If yes, how often? What type of drink: Have you had any surgery: Yes No Do you have any reason to believe you may have been exposed to AIDS(eg. A history of blood transfusion, intravenous drug use, multiple sexual partners or sexual exposure to a gay or bisexual male, exposure to an intravenous drug user)? Yes No Are you ever exposed to chemicals or radiation (eg. X-rays): Yes No Are you on a restricted diet: Yes No Please mark any condition that you have or have had in the past: Cancer Heart disease High blood pressure Kidney disease Liver disease Heptitis Blood clotting disorder HIV/AIDS Epilepsy Diabetes Thyroid disorder Eating disorder Headaches Depression Arthritis or lupus Asthma Anemia Bowel disease Frequent infections Herpes Von Willebrand disease or other bleeding disorder Gynecological disease Sexually transmitted diseases Recurrent urinary tract infections Please indicate whether you or family members had following defects: Mental retardation Birth defects Deformities Hemophilia Muscular dystrophy Cystic firbrosis Aarskog syndrome Acute lymphocytic leukemia Alkaptonuria Allergic conjunctivitis Allergic rhinitis ARTERIOSCLEROSIS_OF_THE_EXTREMITIES Ataxia telangiectasia Canavan disease Cataract Chediak-Higashi syndrome Chronic granulomatous disease Cleidocranial dysostosis Congenital cataract Crohns disease Down syndrome Duchenne muscular dystrophy Duodenal atresia Familial hypertriglyceridemia Familial lipoprotein lipase deficiency Familial Mediterranean fever Fanconis syndrome Gastroschisis Gaucher disease Gilberts syndrome Gilles de la Tourette syndrome Glucagonoma Glucose-6-phosphate dehydrogenase deficiency Hemochromatosis Hunter syndrome Huntingtons disease Hurler syndrome Hyperimmunoglobulin E syndrome Hyperkalemic periodic paralysis Hypertrophic cardiomyopathy Hypokalemic periodic paralysis IgA nephropathy Bergers disease Ischemic cardiomyopathy Krabbe disease Limb-girdle muscular dystrophies McArdle syndrome glycogen storage disease type V Medullary carcinoma of thyroid Metachromatic leukodystrophy Morquio syndrome Multiple Endocrine Neoplasia Myotonia congenita Neuronal ceroid lipofuscinoses Niemann-Pick Noonan syndrome Osler-Weber-Rendu syndrome Osteogenesis imperfecta Peutz-Jeghers syndrome Phenylketonuria Polycystic kidney disease Prader-Willi syndrome Pseudogout Psoriasis guttate Retinitis pigmentosa Rubinstein-Taybi syndrome Sanfilippo syndrome Sjogren syndrome Spinal muscular atrophy Stroke secondary to FMD Thyrotoxic periodic paralysis Von Gierke disease Wilsons disease Were you born when your mother was 35 years or older? Yes No Were you born when your father was 50 years or older? Yes No Have you ever suffered from food poisoning or had contaminated food? Yes No Is your cholesterol high? Yes No Please list any medications taken since your last period, including prescriptions, over-the-counter drugs, multivitamins, other supplements, and any herbal medicines: Please list any illicit or recreational drugs used since your last period (eg. Cocaine, marijuana): Are you pregnant? Yes No When was your last Pap test? Last Month Last Year Last 10 Years Never What was the diagnosis: Have you had: Gonorrhea Chlamydia Pelvic inflammatory disease Syphilis Herpes Have you used intrauterine device for contraception? Yes No Have you been treated for infertility? Yes No   Submit