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Pre-health maintenance examination questions

Please use the following formats when entering in data

Past exams

Last annual health examination
e.g.: 12/2017 or 2017

Known allergies

  • Bee Stings
  • Advil, EPI pen

Current medications

  • Jethrix, 3x day
  • Riladol, 1x day, as needed

Past surgical procedures and significant medical illnesses

  • Appendicitis, 1988
  • Pneumonia, 2018, hospitalization 2 weeks

Family history


  • COPD
  • deceased, 74, lung cancer

Sibling congenital history

  • Brother, deceased, 22, rectal cancer
  • Sister, illness, 42, breast cancer