Health Forms Series 3a


Complete the information in the form.

When was your last checkup?    
Put a check by problems you have had:  
allergies   asthma   cancer   diabetes   headaches  

heart attack   high blood pressuretuberculosis

Did you ever stay in the hospital?  Yes No  If yes, what for?  
surgery   illness   pregnancy   delivery  

other:  explain


What is your problem today?