Medical History

PERSONAL HISTORY

Name

Date

Birth Date

Home Phone

Work Phone

Occupation

Hours per Week

Shift Work

Y N

How long have you performed this type of work?

Education level

If applicable, college degree(s), year and field.

Marital Status

S M D W Cohabitating

Spouse or Significant Other's name

Number of Children

List the year(s) of their birth(s)

Recreation or Hobbies

Exercise (Frequency and Duration)

Sleep

Quality

Poor Fair Good Excellent

Do you take sleeping aids?

Y N

Type

HABITS:

Caffeine

No Yes Quit

Type

Recreational Drugs

No Yes Quit

Type

If yes, any IV use in the past?

Yes No

Alcohol

No Yes Quit

Type

Tobacco

No Yes Quit

Type

PAST MEDICAL HISTORY

Have you ever had:

Anemia

Yes No

Year

Hepatitis (yellow jaundice)

Yes No

Year

Arthritis

Yes No

Year

High Blood Pressure

Yes No

Year

Asthma

Yes No

Year

Hives

Yes No

Year

Bladder Infection

Yes No

Year

Infectious Mono

Yes No

Year

Bleeding Tendency

Yes No

Year

Kidney Disease

Yes No

Year

Blood Transfusion

Yes No

Year

Malaria

Yes No

Year

Bronchitis

Yes No

Year

Meningitis

Yes No

Year

Cancer

Yes No

Year

Mental Illness

Yes No

Year

Chronic Diarrhea

Yes No

Year

Nosebleeds

Yes No

Year

Chronic Lung Disease

Yes No

Year

Obesity

Yes No

Year

Depression

Yes No

Year

Pneumonia

Yes No

Year

Emphysema

Yes No

Year

Polio

Yes No

Year

Epilepsy

Yes No

Year

Repeated Infections

Yes No

Year

Hay Fever

Yes No

Year

Seizures

Yes No

Year

Heart Disease

Yes No

Year

Sinusitis, chronic

Yes No

Year

Headaches

Yes No

Year

TB or exposure to

Yes No

Year

Hemorrhoids

Yes No

Year

Other. If so, please sepcify.

HOSPITALIZATIONS: Reason and year

Medication List

Your information will be encrypted.

Loading...