Major Illnesses:
Circle any of the following conditions that you have been diagnosed with:
Colon polyps Colon Cancer
Irritable bowel syndrome Spastic colon
Ulcerative colitis Crohn’s disease
Hepatitis Jaundice
Gallstones Pancreatitis
Ulcer in the stomach? In the duodenum?
Was it related to aspirin usage?
Was it related to nsaid medications (ibuprofen/aleve/motrin etc.)
Were you diagnosed with H. pylori bacteria?
History of any high blood pressure even if now controlled?
History of elevated cholesterol?
Heart disease
Mitral valve prolapse
Leaky heart valve
Heart valve blockage (stenosis)
Artificial heart valve
Endocarditis (heart infection)
Blood clots (leg) (lung)
Artificial joint prosthesis/replacement
Seizure Stroke TIA
Kidney stone Kidney dysfunction Kidney failure/dialysis
Bleeding disorders
Cancer:
Involving
GI: Rectum Colon Stomach Esophagus
GU
Bladder
Prostate
` Cervix Uterus Ovary
Breast