T.W.U. Institute for Women's Health Pioneer Project

Year 1 Medical History Questionnaire
Personal Medical History

Section 3: Review of Systems


Please indicate whether you have had a significant problem with any of the symptoms or conditions listed below. If it is a problem that has happened more than once, mark "recurring" as well as all ranges of years in which it happened.

26. NEUROLOGICAL AND PSYCHIATRIC
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Loss of consciousness
Vertigo
Frequent headaches
Migraine headaches
Treatment for nervous disorder
Numbness or tingling or arms, legs, or face
Difficulty sleeping
Depression
Anxiety
Thoughts of suicide
Psychiatric counseling or psychological counseling
Parkinson's Disease
ALS (motor neuron disease, Lou Gehrig's disease)
Meningitis
Substance/drug dependence
 
27. DERMATOLOGY
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Skin rash
Skin cancer
Shingles (herpes zoster)
Skin sores
Unusual moles
Mouth sores that won't heal
Skin sores that won't heal
Scleroderma
Polymyosistis/Dermatomyositis
Other skin problems
 
28. CHILDHOOD DISEASES
YEAR OF FIRST DIAGNOSIS
10+ years
ago
6-10 years
ago
1-5 years
ago
within past
year
no
response given
currently
experiencing
recurring
Chicken pox
German measles (rubella)
Red measles
Mumps
Scarlett fever