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GCK Solutions Annual Wellness - Dr. John's Clinic Logout

Name: jane doe Referred Doctor: Dr. Peter Hopkins
DOB/Sex : 1977-05-09 / Male Physician ID: PY3085
Email : admin@gcksolutions.com Patient ID: PTIM707
Phone: 9999999999

Medical History

Your History: Please check the appropriate box for the conditions as they apply to you:

Heart attack
Rheumatic Fever
Heart murmur
Diseases of the arteries
Varicose veins
Arthritis of legs or arms
Diabetes or abnormal blood sugar tests
Phlebitis (inflammation of a vein)
Dizziness or fainting spells
Epilepsy or seizures
Stroke
Diphtheria
Scarlet Fever
Infectious mononucleosis
Nervous or emotional problems
Anemia
Thyroid problems
Pneumonia
Bronchitis
Asthma
Abnormal chest X ray
Other lung disease
Injuries to back, arms, legs or joint
Broken bones
Jaundice or gall bladder problems
Has a doctor ever said your blood pressure was too high?
Do you ever have pain in your chest or heart?
Are you often bothered by a thumping of the heart?
Does your heart often race?
Do you ever notice extra heartbeats or skipped beats?
Are your ankles often badly swollen?
Do cold hands or feet trouble you even in hot weather?
Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary?
Do you suffer from frequent cramps in your legs?
Do you often have difficulty breathing?
Do you get out of breath long before anyone else?
Do you sometimes get out of breath when sitting still or sleeping?
Has a doctor ever told you your cholesterol level was high?
Has a doctor ever told you that you have an abdominal aortic aneurysm?
Has a doctor ever told you that you have critical aortic stenosis?
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