Activate the Cat Medical History Log:
Full Name of Resident:
First Name
Last Name
Room Number:
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Month
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Day
Year
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Name Of Establishment
Person Filling Out The Form:
Check all that apply
Asthma / Lung Problems
Cancer
Cardiac Disease
Diabetes
History of Back Pain
Hypertension
Psychiatric Disorders
Seizure Disorder
Stroke
Asthma Syptoms
coughing
wheezing
Shortness of breath
tightness in chest
Types of Diabetes
Recently Diagnosed
Type 1
Type 2
I have Gestational Diabetes
Not sure what Type?
Types of Back Pain
Acute pain
Chronic pain
Neuropathic pain
Types of Heart Disease
Angina pectoris
angina
Atrial fibrillation
Congestive heart failure
Mitral stenosis
Check all symptoms you might observe
Allergy
Cardiovascular
Chest Pain
Connective Tissue Disease
Eating Disorder
Ear / Nose / Throat
Eye
Fever
Gastrointestinal
Genitourinary
Hemtalogical
Lymphatic
Musculoskeletal Pain
Neurological
Psychiatric
Respiratory
Skin
Weight Gain
Weight Loss
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