Free Medical History Checklist

Individual's Health Record

• Acute Illnesses (e.g., flu, infections)

• Chronic Illnesses (e.g., diabetes, hypertension)

• Surgeries and Hospitalizations (specify type and date)

• Medications Currently Taken (list names and dosages)

• Past Medical Conditions

Past Treatments and Outcomes

• Diagnosed Conditions (specify diagnosis)

• Details of Treatments (include therapy type and duration)

• Outcome of Treatments (improved, unchanged, worsened)

Previous Medications and Procedures

• Medications Taken in the Past (list names and dosages)

• Medical Procedures Undergone (specify type and date)

Allergies

• Food Allergies (specify allergens)

• Medicinal Allergies (specify medications)

• Environmental Allergies (specify allergens)

Family Health History

• Parent's Health History (include major illnesses, if deceased cause and age)

• Sibling's Health History (include major illnesses or conditions)

• Grandparent's Health History (include major illnesses, if deceased cause and age)

Lifestyle Factors

• Smoking History

• Alcohol Consumption

• Exercise Routine (frequency and type)

• Dietary Habits (e.g., vegetarian, low carb)

Psychosocial History

• Stress Levels (low, moderate, high)

• Mental Health History (e.g., depression, anxiety)

• Social Support System (family, friends, community)

Consent and Acknowledgement

• Consent to Share Medical Information (with specified entities)

• Acknowledgment of Information Accuracy

• Please ensure all information is complete and accurate to the best of your knowledge.

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