Your answers on this form will provide PanoHealth an accurate history of your medical conditions. It will be stored de-identified along with your donated blood sample in the repository. Please complete all sections. It is long because this comprehensive data is best for utility in future research. If you cannot remember specific details, please provide your best guess. If you are uncomfortable with any question, do not answer it. Thank you!
Race (choose all that apply):
Have you recently been diagnosed with an acute infection (eg. influenza, sinus infection, COVID-19, UTI, etc.)?
MEDICATIONS: Please list all prescriptions and non-prescription medications. This includes vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc.)
Dose (e.g. mg/pill)
How many times per day
ALLERGIES or intolerance to medications?
IMMUNIZATIONS: Enter year (if known) of any vaccinations you have had.
HEALTH MAINTENANCE SCREENING TESTS
PERSONAL MEDICAL HISTORY: Do you have now or have you had (past) any of the following conditions?
Alcohol / Drug abuse
Alcohol / Drug abuse When
Arthritis (Rheumatoid) When
Arthritis (Osteoarthritis) When
Bladder / Kidney Problems
Bladder / Kidney Problems When
Breast Lump (benign) When
Coronary Artery Disease When
Diabetes (adult onset) When
Diabetes (childhood onset)
Diabetes (childhood onset) When
Fractures (broken bones) When
Gastroesophageal Reflux (Heartburn/GERD)
Gastroesophageal Reflux (Heartburn/GERD) When
Gynecological Conditions (Endometriosis)
Gynecological Conditions (Endometriosis) When
Gynecological Conditions (Fibroids)
Gynecological Conditions (Fibroids) When
Gynecological Conditions (Other)
Gynecological Conditions (Other) When
Irritable Bowel Syndrome When
Kidney Disease / Failure When
Prostate (enlargement) When
Skin Condition (Eczema) When
Skin Condition (Psoriasis)
Skin Condition (Psoriasis) When
Skin Condition (Abnormal Moles)
Skin Condition (Abnormal Moles) When
Thyroid High (Overactive) / Hyperthyroidism
Thyroid High (Overactive) / Hyperthyroidism When
Thyroid Low (Underactive) / Hypothyroidism
Thyroid Low (Underactive) / Hypothyroidism When
SURGICAL & PROCEDURE HISTORY: Please check off any procedure or surgeries. List any abnormal finding, details or complications under comments.
Appendectomy (appendix removal)
Biopsy (location in comments)
Gallbladder Removal Comments
Heart Surgery (other than coronary bypass checked above)
Hysterectomy (partial, ovaries left)
Hysterectomy (total, including ovaries)
Stress Test (stress echo)
Stress Test (thallium/perfusion)
If adopted and you do not know your family history skip the Family History section and continue to Health Issues.
Indicate which relative has had the following diseases (parents, brothers & sisters are the most important). Write in number of siblings in appropriate boxes. *If some siblings are alive and some are deceased use the space to explain further.
Age currently or at death
Diseases & Conditions
List age(s) at diagnosis if known and if this was the cause of death
No significant history known
No significant history known Relatives
Hypertension – high blood pressure
Hypertension – high blood pressure Relatives
Hyperlipidemia – high cholesterol
Hyperlipidemia – high cholesterol Relatives
Heart Attack, Angina (Coronary Artery Disease)
Heart Attack, Angina (Coronary Artery Disease) Relatives
Diabetes Type II (adult onset)
Diabetes Type II (adult onset) Relatives
Cancer, Prostate Relatives
Alcoholism / Drug abuse
Alcoholism / Drug abuse Relatives
Autoimmune Disease Relatives
Bleeding or Clotting Disorder
Bleeding or Clotting Disorder Relatives
Cancer, Ovarian Relatives
Cancer, Other type Relatives
Diabetes Type I (childhood onset)
Diabetes Type I (childhood onset) Relatives
Emphysema (COPD) Relatives
Genetic Disorder (explain)
Genetic Disorder (explain) Relatives
Heart Disease (CHF) Relatives
Heart Disease (Other) Relatives
Hepatitis B or C Relatives
Hypothyroidism / Thyroid Disease
Hypothyroidism / Thyroid Disease Relatives
Macular Degeneration Relatives
Sudden Cardiac Death Relatives
Exposure to second hand smoke?
Have you ever used recreational drugs?
Sexual partner(s) is/are/have been/may be in future:
Birth control method or STD prevention (check all that apply):
Exposure to toxic chemicals at work?
Exposure to toxic chemicals doing hobbies?
Do you exercise regularly?
Do you use seatbelts consistently?
In the past 2 weeks have you been feeling down, depressed or hopeless?
Do you have little interest or pleasure in doing things?
Does your home have a working smoke detector?
Do you have guns in your home?
Are they locked up & ammo stored separately?
Have you or any family members ever been hurt, insulted, threatened or screamed at?
Who lives at home with you?
Please check any of the following forms you have completed:
Do you have concerns about your periods or menopause you’d like to discuss?