Medical Health Questionnaire - My Doctor Online The Permanente ...

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PERSONAL SURGICAL HISTORY (continued) Hip surgery YES NO Hysterectomy (ovaries removed) YES NO Hysterectomy (ovaries left) YES NO COMMENT: COMMENT: COMMENT: Knee surgery YES NO COMMENT: Neck surgery YES NO COMMENT: Tubal ligation YES NO COMMENT: Spleen removed YES NO COMMENT: Other MEDICATIONS NAME DOSE DIRECTIONS DRUG ALLERGIES DRUG NAME REACTION Member Health History © 2012 Kaiser Permanente — All Rights Reserved DRAFT FORM No. XXX Page 3 of 5
FAMILY HISTORY (check all that apply) Member Health History NONE MOTHER FATHER SISTER BROTHER GRANDMOTHER GRANDFATHER Healthy Heart Disease Diabetes Drug Addiction Hypertension Hyperlipidemia Stroke Colon Cancer Colon Polyp Breast Cancer Prostate Cancer Alzheimer Disease Osteoporosis Aortic Aneurysm Alcohol Problem Anxiety Bleeding Disorder Clotting Disorder Depression Genetic Disorder Hemochromatosis Hepatitis Ovarian Cancer Panic Disorder Tuberculosis Thyroid Cancer Thyroid Disorder © 2012 Kaiser Permanente — All Rights Reserved DRAFT FORM No. XXX Page 4 of 5
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Page 3: PERSONAL MEDICAL HISTORY (continued

Medical Health Questionnaire - My Doctor Online The Permanente ...

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