Date Completed________________



SUBJECT GENERAL MEDICAL HISTORY FORM PART A

Demographics

Date Completed________________ Reviewed By____________ Date___________

First Name______________________________ Last Name __________________________

Address: ________________________________________________________________________ City _______________

Tel: Home________________________ Work _______________________________ Mobile ______________________

Social Security Number ______ - ______- ______ Sex: M F (Please circle)

Race: Caucasian Hispanic African-American Asian-American American-Indian Other_____________ (Please Circle)

Allergy History

1. Are you allergic to any medication? N Y Type of Reaction Date

If Yes, List Medication Name ____________________ ________________ _____________

____________________ _________________ _____________

2. Do you have environmental allergies? N Y Date Started________________ Date Diagnosed ______________

Circle all that apply

Itchy Nose Sneezing Stuffy Nose Runny Nose Postnasal Drip Itchy Palate Cough Itchy Throat

Watery Eyes Itchy Eyes Red Eyes Swollen, Puffy Eyes Ear Fullness Itchy Ears Allergy Headache

Facial Pressure/Pain Itchy Skin Fatigue Sore Throat Other _______________________

3. Do you seem to have symptoms all year long? N Y

4. Do you have a worsening of symptoms during certain seasons? N Y Spring Summer Fall Winter

5. Have you been tested to see what you are allergic to? N Y List _________________________________

6. Do you currently receive allergy shots? N Y Started? ___________________

Have you reached your maintenance dose? N Y Date ______________________

7. How often do you receive your allergy shots? __________________________________

Other______________________________________________________________________________

Asthma History

1. Do you have asthma? N Y Year symptoms started____________ Year Diagnosed___________

2. What makes your asthma symptoms worse? Circle all that apply

Exercise Tobacco Smoke Animals Dust Mold Humidity Cold Air

Emotions Weather Changes Perfume Cleaning Agents Allergies Grass

Foods Laughing/Crying Lying Down Stress Withholding Asthma Medications

Other_____________________________________________________________________________

Tobacco and Alcohol History

1. Are you currently using tobacco? N Y Type______________________

2. Have you ever used tobacco? N Y Type______________________

Date started_____________ Date Quit ________________ How much per day_________________

3. Are you currently using alcohol? N Y

Type________________________ How often_______________________

Reproductive History

1. If Male, have you had a vasectomy? N Y Date___________________

You may skip to Section B.

2. If Female, have you started your period? N Y At what age? ____________

Is your cycle regular? Y N Explain_________________

3. Have you gone through menopause? N Y Date____________________

If yes, date of last period? Date ___________

4. Have you had a hysterectomy? N Y Date____________________

5. Have you had a tubal ligation? N Y Date____________________

6. What method of birth control are you currently using? ______________________________ Since______________

Surgical History

1. None (

2. List Surgical Procedure Date Performed Hospital

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

When reviewing the following pages, please indicate if you have EVER experienced a problem by checking the line next to it. Please put the YEAR the symptoms first started on the line. Please leave the gray area blank. If you have questions a coordinator will be happy to assist you.

Ophthalmic History (eye)

(Staff only)

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Glaucoma ______ ______ ______ ____________________________________

2. Glasses ______ ______ ______ ____________________________________

3. Cataracts ______ ______ ______ ____________________________________

4. Contact Lenses ______ ______ ______ ____________________________________

5. Nearsighted ______ ______ ______ ____________________________________

(cannot see far away)

6. Farsighted ______ ______ ______ ____________________________________

(cannot see close up)

7. Trauma ______ ______ ______ ____________________________________

8. Astigmatism ______ ______ ______ ____________________________________

9. Other ______ ______ ______ ____________________________________

Ear, Nose, Throat History

(Staff only)

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Sinus Infection-Last ______ ______ ______ ___________________________________

2. Nasal Polyps ______ ______ ______ ___________________________________

3. Sinus Headaches ______ ______ ______ ___________________________________

4. Hearing Loss (Diagnosed) ______ ______ ______ ___________________________________

5. Deviated Septum ______ ______ ______ ___________________________________

6. Ear Infections/Tubes ______ ______ ______ ___________________________________

8. Nasal Congestion ______ ______ ______ ___________________________________

9. Recurrent Strep Throat ______ ______ ______ ___________________________________

10. Tonsillitis/Pharyngitis ______ ______ ______ ___________________________________

11. Other ______ ______ ______ ___________________________________

Endocrine History

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Thyroid Disorder ______ ______ ______ ___________________________________

2. Diabetes ______ ______ ______ ___________________________________

3. Delayed Growth ______ ______ ______ ___________________________________

4. Pancreatitis ______ ______ ______ ___________________________________

5. Abnormal Lymph Glands ______ ______ ______ ___________________________________

6. Other ______ ______ ______ ___________________________________

Genitourinary History

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Prostate Disorder ______ ______ ______ ___________________________________

2. Ovarian Cysts ______ ______ ______ ___________________________________

3. Menstrual Cramps ______ ______ ______ ___________________________________

4. Kidney Stones ______ ______ ______ ___________________________________

5. Urinary Tract Infection ______ ______ ______ ___________________________________

6. Other ______ ______ ______ ___________________________________

Cardiac History (Heart)

(Staff only)

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. High Blood Pressure ______ ______ ______ ___________________________________

2. Irregular Heart Beat ______ ______ ______ ___________________________________

3. Murmur ______ ______ ______ ___________________________________

4. Chest Pain ______ ______ ______ ___________________________________

5. Heart Attack ______ ______ ______ ___________________________________

6. Blood Clots ______ ______ ______ ___________________________________

7. Mitral Valve Prolapse ______ ______ ______ ___________________________________

8. Other ______ ______ ______ ___________________________________

Pulmonary History (Lungs)

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Pneumonia-Last ______ ______ ______ ___________________________________

2. Bronchitis-Last ______ ______ ______ ___________________________________

3. Emphysema ______ ______ ______ ___________________________________

4. Upper Respiratory ______ ______ ______ ___________________________________

Infection

5. Shortness of Breath ______ ______ ______ ___________________________________

6. Croup ______ ______ ______ ___________________________________

7. Collapsed Lung ______ ______ ______ ___________________________________

8. RSV ______ ______ ______ ___________________________________

9. Other ______ ______ ______ ___________________________________

Blood History

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Anemia ______ ______ ______ ___________________________________

2. Jaundice ______ ______ ______ ___________________________________

3. Abnormal Values ______ ______ ______ ___________________________________

(ie: high cholesterol, high liver values)

4. Bad Veins ______ ______ ______ ___________________________________

5. Fear of Needles ______ ______ ______ ___________________________________

6. Other ______ ______ ______ ___________________________________

Skin, Scalp, & Nail History

(Staff only)

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Acne ______ ______ ______ ___________________________________

2. Hives ______ ______ ______ ___________________________________

3. Fungal Infections ______ ______ ______ ___________________________________

4. Psoriasis/Eczema ______ ______ ______ ___________________________________

5. Breast Mass ______ ______ ______ ___________________________________

6. Other ______ ______ ______ ___________________________________

Gastrointestinal History

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Irritable Bowel Syndrome ______ ______ ______ ___________________________________

(Diagnosed)

2. Crohn’s Disease ______ ______ ______ ___________________________________

3. Ulcers ______ ______ ______ ___________________________________

4. Hernia –Type: ______ ______ ______ ___________________________________

5. Colon Polyps ______ ______ ______ ___________________________________

6. Gastric Reflux Disease ______ ______ ______ ___________________________________

7. Frequent Heartburn ______ ______ ______ ___________________________________

8. Frequent Nausea/Vomiting ______ ______ ______ ___________________________________

9. Other ______ ______ ______ ___________________________________

Neurological History

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Migraine Headaches ______ ______ ______ ___________________________________

2. Tension Headaches ______ ______ ______ ___________________________________

3. General Headaches ______ ______ ______ ___________________________________

4. Depression ______ ______ ______ ___________________________________

5. Numbness ______ ______ ______ ___________________________________

6. Seizures ______ ______ ______ ___________________________________

7. Epilepsy ______ ______ ______ ___________________________________

8. Other ______ ______ ______ ___________________________________

Musculoskeletal History

(Staff only)

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Diagnosed Arthritis ______ ______ ______ ___________________________________

Type:

2. Osteoporosis ______ ______ ______ ___________________________________

3. Frequent Back Pain ______ ______ ______ ___________________________________

4. Frequent Muscle Pain ______ ______ ______ ___________________________________

5. Frequent Joint Pain ______ ______ ______ ___________________________________

6. Bursitis ______ ______ ______ ___________________________________

7. Broken Bone: ______ ______ ______ ___________________________________

8. Broken Bone ______ ______ ______ ___________________________________

9. Broken Bone ______ ______ ______ ___________________________________

10. Other ______ ______ ______ ___________________________________

Miscellaneous History

Check if Year Current Changes to original medical history

Experienced began yes no Change initial/date

1. Rheumatic Fever ______ ______ ______ ___________________________________

2. Measles ______ ______ ______ ___________________________________

3. Mumps ______ ______ ______ ___________________________________

4. Chicken Pox ______ ______ ______ ___________________________________

5. Fifth Disease ______ ______ ______ ___________________________________

6. Polio ______ ______ ______ ___________________________________

7. Cystic Fibrosis ______ ______ ______ ___________________________________

8. Tuberculosis ______ ______ ______ ___________________________________

9. Cancer ______ ______ ______ ___________________________________

10. Hepatitis ______ ______ ______ ___________________________________

Type:

11. Abnormal Chest X-Ray ______ ______ ______ ___________________________________

12. Other ______ ______ ______ ___________________________________

Comments

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Version Gen Doc Nov 2009

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I have accurately described my (my child’s) medical history to the best of my knowledge.

___________________________________________________ ______________________

Signature of Patient Date

___________________________________________________ ______________________

Signature of Parent or Legal Guardian Date

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original.

Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original.

Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date_______________________

Signature of Patient or Legal Guardian

( Changes were made to this original. Date________________________

Signature of Patient or Legal Guardian

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