Medical History Interview Form

Parent 1
Date of birth
21. July 1964
Date of death
(Alive)
Age 49
Medical History
Psychological Illness
Name
Onset
Duration
Acute/Chronic

-
-
-
-

Potential Causes

-
Medical Illness
Name
Onset
Duration
Acute/Chronic

Gastritis
Mid 1990s ~
Still present
Chronic

Potential Causes

Diet – excessive coffee drinking and a great fondness for spicy food1
Stress – has multiple chronic stressors from role overload2
Comment
Except Gastritis, the individual is perfectly healthy, both mind and the body. She has been regularly exercising in the local community centre swimming pool for more than 15 years as well as playing golf occasionally. Even though the person encounters many occasions that could upset the person greatly, the person has many friends and family members to provide social support when needed.

Parent 2
Date of birth
05. May 1960
Date of death
(Alive)
Age 53
Medical History
Psychological Illness
Name
Onset
Duration
Acute/Chronic

-
-
-
-

Potential Causes

-
Medical Illness
Name
Onset
Duration
Acute/Chronic

Hepatitis B
(chronic carrier)
Unknown
Still Present
Chronic

Potential Causes

Viral infection from transfusion or sexual contact 3

Name
Onset
Duration
Acute/Chronic

Cataract
2011~
2 yrs (~Sep. 2013)
Chronic

Potential Causes

Biological aging
Health-compromising behaviour (smoking) 4– yet, it is assumed that possibility that this affected the medical condition is rather low

Name
Onset
Duration
Acute/Chronic

Fatty Liver Disease(alcoholic steatosis)
Early 2000s ~
Still Present
Chronic

Potential Causes

Health-compromising behaviour – mainly excessive alcohol intake due to the individual’s occupational requirements
Comment
Due to the occupational reasons, the individual’s weekly alcohol consumption is insurmountable. Yet, the person has a number of healthy habits, such as playing golf and keeping regular mealtime, which