Page 2 F-1(LE) Rev. 6/11
Past Medical History
List ALL hospitalizations and operations since childhood:
(Include type of surgery, date of surgery, any complications or other significant information)
Have you EVER, in your life, had any of the following types of medical problems? [check all that apply to you]
1. CANCER: any type of cancer including skin cancer, breast cancer, and leukemia?
2. MAJOR INFECTIOUS DISEASE: such as tuberculosis, hepatitis, HIV/AIDS, rheumatic fever and others?
3. NEUROLOGICAL PROBLEMS: such as seizure disorder, stroke, concussion, severe headache, skull fracture,
recurrent vertigo, balance problems, encephalitis, meningitis, tremors, multiple sclerosis, Huntington=s chorea,
peripheral neuropathy and others?
4. PSYCHOLOGICAL PROBLEMS: such as depression, manic episodes, psychotic episodes, post traumatic
stress disorder and others?
5. EYE PROBLEMS: such as eye injury, color blindness, poor night vision (night blindness), glaucoma,
blindness in one or both eyes, very poor vision when not corrected and others?
6. EAR PROBLEMS: such as ear injury, chronic ringing (tinnitus), chronic or long lasting ear infection,
Meniere=s disease, moderate to severe hearing loss in one or both ears and others?
7. NOSE PROBLEMS: such as nose injury, allergies, nasal bleeding, loss of sense of smell, chronic or long
lasting infections and others?
8. MOUTH OR THROAT PROBLEMS: such as injury, major dental work, any kind of speech defect, chronic
or long lasting infections, abnormality of nose, mouth or throat that would interfere with wearing a respirator
9. LUNG PROBLEMS: such as asthma, emphysema, chronic or recurrent bronchitis, pneumonia, tuberculosis or
lung abscess and others?
10. HEART AND CIRCULATION PROBLEMS: such as heart murmur, heart disease, heart attack, hypertension
(high blood pressure) irregular rhythm, valve abnormalities, varicose veins, phlebitis, peripheral vascular
disease, Raynaud=s disease and others?
11. DIGESTIVE SYSTEM PROBLEMS: such as any kind of ulcer disease, hepatitis or liver disorder, any kind of
colitis, Crohn=s disease, ulcerative colitis, irritable bowel syndrome, esophageal disorders, pancreatitis, gall
stones, stomach or intestinal bleeding and others?
12. HORMONE OR ENDOCRINE PROBLEMS: such as diabetes, thyroid disease, parathyroid or adrenal
problems and others?
13. URINARY TRACT PROBLEMS: such as kidney stones, pyelonephritis (kidney infection), nephrosis, single
functioning kidney, polycystic kidney disease, repeated bladder infections and others?
14. HERNIA: such as inguinal, umbilical, ventral, femoral, hiatal or incisional hernias?
15. MUSCLE, BONE AND JOINT PROBLEMS: such as chronic back or neck pain, numbness fibromyalgia, back
or neck disk disease, osteomyelitis (bone infection), muscular dystrophy, arthritis, spinal curvature, carpal tunnel
syndrome loss of a finger or toe, and others?
16. BLOOD SYSTEM PROBLEMS: such as anemia, hemophilia or bleeding disorder, white blood cell
abnormality and others?
(Continued on next page)