University of Nebraska Omaha



Allergies ____________________________MRN___________________________MEDICAL HISTORY PAST AND/OR PRESENTAllergies□ yes □ noCoronary Art Disease□ yes □ noMeningitis□ yes □ noAlzheimer’s Disease□ yes □ noDementia□ yes □ noMRI Incompatibility□ yes □ noAnemia□ yes □ noDepression□ yes □ noMyocardial Infarction□ yes □ noAnxiety□ yes □ noDiabetes Mellitus□ yes □ noNerve/Muscle disease□ yes □ noArthritis□ yes □ noEmphysema□ yes □ noOsteoporosis□ yes □ noAsthma□ yes □ noGERD□ yes □ noSeizures□ yes □ noAtrial Fibrillation□ yes □ noGestational Diabetes□ yes □ noSickle cell anemia□ yes □ noBlood Transfusion□ yes □ noGlaucoma□ yes □ noStroke□ yes □ noCancer□ yes □ noHeart murmur□ yes □ noSubstance Abuse□ yes □ noCataracts□ yes □ noHIV/AIDS□ yes □ noThyroid disease□ yes □ noCHF□ yes □ noHypercholesterolemia□ yes □ noTuberculosis□ yes □ noClotting disorder□ yes □ noHypertension□ yes □ noVenous insufficiency□ yes □ noCOPD□ yes □ noKidney disease□ yes □ noSURGICAL HISTORY PAST AND/OR PRESENTAppendectomy□ yes □ noC-Section□ yes □ noOpen Hysterectomy□ yes □ noBrain surgery□ yes □ noEye surgery□ yes □ noSmall intestine surgery□ yes □ noBreast surgery□ yes □ noFracture surgery□ yes □ noSpine surgery□ yes □ noCABG□ yes □ noHernia repair□ yes □ noTonsillectomy□ yes □ noCholecystectomy□ yes □ noJoint replacement□ yes □ noTubal ligation□ yes □ noColon surgery□ yes □ noLaparoscopic hysterectomy□ yes □ noValve replacement□ yes □ noCosmetic surgery□ yes □ noFAMILY HISTORY – check illnesses that have occurred in any blood relatives & specify relationship to you.No known problems□ yes □ noDepression□ yes □ noMental illness□ yes □ noAlcohol Abuse□ yes □ noDiabetes Mellitus□ yes □ noMiscarriage□ yes □ noArthritis□ yes □ noDrug Abuse□ yes □ noProstate Cancer□ yes □ noAsthma□ yes □ noHeart Disease□ yes □ noStroke□ yes □ noBreast Cancer□ yes □ noHyperlipidemia□ yes □ noParkinson’s Disease□ yes □ noCancer□ yes □ noHypertension□ yes □ noAdopted□ yes □ noColon Cancer□ yes □ noKidney Disease□ yes □ noFamily Hx Unknown□ yes □ noCOPD□ yes □ noLearning Disabilities□ yes □ noSOCIAL HISTORYAbuse HistoryVerbal?□ yes □ noPhysical?□ yes □ noSexual?□ yes □ noTobacco HistoryUse?□ yes □ noPrevious user?□ yes □ noStart Date__________Quit Date?_________Cigarettes□ yes □ noPipe□ yes □ noSmokeless Tobacco□ yes □ noPacks/Day_________Years?_________If YES, would you like quit smoking counseling?□ yes □ noSecond Hand Smoke Exposure□ yes □ noSource?___________Alcohol Use□ yes □ noDrinks/week?Wine_________Beer__________Shots/Liquor_________Drug Use□ yes □ noType?_________________________________________If YES, would you like a brief discussion about drug use?□ yes □ noSexual HistoryActive□ yes □ no□ not currentlyBirth control□ yes □ noPartners?□ Male □ FemaleType?__________How many partners in last year?_____________Most recent sexual activity?_____________Sexual identity____________School/Home/WorkCommunity StatusStudent?□ yes □ noSchool attends_____________Employment?□ yes □ noVolunteer?□ yes □ noAttends church□ yes □ noSpecial needs?□ yes □ noSports/activities□ yes □ noLives with?____________ ................
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