LHRI Clinical Research Services

University of Rochester Subject Initials ______

First Middle Last

STUDY PROTOCOL #: ______Subject Number: ______

PATIENT MEDICAL HISTORY

NAME: ______

First Middle Last

Address: ______

City/Town: ______Zip Code ______

Telephone Number: Day ______Evenings ______

Date of Birth _____/_____/_____ Ethnic Origin: ______Caucasian

Day Month Year ______Black

______Hispanic

______Asian

______Other

Sex: M F

Name of Family Physician: ______

Address:______

Name of Other Doctor(s) (Specialists): ______

______

This information is to be used by medical staff to screen for possible eligibility in a clinical research study. Patients are told that giving false, incomplete or misleading information about their medical history could have serious consequences to their health while participating in a clinical trial. All information received in this document is kept completely confidential.

MEDICAL / SURGICAL HISTORY

Have you had any operations? If YES, please list below: NO YES

CONDITION / DATE (MM/YY) / CONTINUES?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO

PREVIOUS HOSPITALIZATIONS

NO YES

If YES, list below any hospitalizations NOT listed in SURGICAL HISTORY

REASON / DATE (MM/YY)

CURRENT MEDICATIONS NO YES

Have you taken any medication in the last 30 days?  

List any and all medications you have taken (including any over-the-counter products (OTC),

Medication / OTC or
RX / Dosage / Frequency / Date of
First Dose / Date of
Last Dose
(Complete only if discontinued) / Reason
Ex. Tylenol / OTC / 325 mg. / Twice/day / 02JAN2012 / 04JAN2012 / Headache

ALLERGIES AND SENSITIVITIES

Do you have any allergies or sensitivities? NO YES

If YES, indicate below:

Type may include: Medication, Food, Environmental, etc.

Type of Allergy / Name of Allergen / Date of Onset / Symptom/Reaction

FEMALES ONLY (for males check N/A )

Contraception

Forms of birth control you are currently using (check):

 Abstinence  Diaphragm & Spermicide  Post menopausal for 2 years +

 Condom  Hysterectomy  Tubal Ligation

 I.U.D.  Condom & Spermicide  Vasectomized Partner

 Diaphragm  Oral Contraceptive (pill)  Other ______

 Norplant Date of Implant:______

 Depo-Provera: Last injection date: ______

Specify date if applicable: ______

Are you currently nursing (breast-feeding)? NO YES

SYSTEM REVIEW

Do you have or have you ever had any disorder of the EYES, EARS,NOSE OR THROAT? NO YES

Condition/Diagnosis / Date of Onset or Diagnosis / Active or Non-Active

Do you have or have you ever had any CARDIOVASCULAR disorders? NO YES

Condition/Dianosis / Date of Onset or Diagnosis / Active or Non-Active

Do you have or have you ever had any Respiratory disorders? No Yes

Condition/Diagnosis / Date of Onset or Diagnosis / Active or Non-Active

Do you have or have you ever had any GASTROINTESTINAL disorders? NO YES

Condition/Diagnosis / Date of Onset or Diagnosis / Active or Non-Active

Do you have or have you ever had any GENITOURINARY-REPRODUCTIVE disorders? NO YES

Condition/Diagnosis / Date of Onset or Diagnosis / Active or Non-Active

Do you have or have you ever had any MUSCULOSKELETAL disorders? NO YES

Condition /Diagnosis / Date of Onset or Diagnosis / Active or Non-Active

Do you have or have you ever had any NEUROLOGICAL-PSYCHIATRIC disorders? NO YES