SUBJECT GENERAL MEDICAL HISTORY FORM PART A
Demographics
Date Completed: / Reviewed by: / Date:
Last Name: / First: / Middle:
Address:
/ City/State:Home Phone: / Cell Phone: / Work Phone:
Social Security Number: / Sex: Male ☐ Female ☐
Race: ☐Caucasian ☐Hispanic ☐African-American ☐Asian-American ☐American Indian Other______
Allergy History- Are you allergic to any medication? * Yes ☐No ☐ *If yes, List Medication Name below
Medication Name
Type of Reaction:
Date:
- Do you have environmental allergies? *Yes ☐No ☐
*If yes, Date Started: / Date Diagnosed:
√ 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 Throat ☐Itchy Ears ☐Allergy Headache
☐Facial Pressure/Pain ☐Itchy Skin ☐Fatigue ☐Sore Throat ☐Congestion ☐Other
- Do you seem to have symptoms all year long? Yes ☐No ☐
- Do you have worsening of symptoms during certain seasons? Yes ☐No ☐
- Have you been tested to see what you are allergic to? *Yes ☐No ☐ *If yes, list below
- Do you currently receive allergy shots? Yes ☐No ☐
Have you reached your maintenance dose? Yes ☐No ☐ / Date:
- How often do you receive your allergy shots?
Asthma History
1.Do you have asthma? *Yes ☐No ☐
*If yes, Year Started: / Year Diagnosed:
2.What makes your asthma symptoms worse?
√ 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
- Are you currently using tobacco? Yes ☐No ☐
- Have you ever used tobacco? Yes ☐No ☐
If yes, Date Started: / Date Quit: / How much per day
- Are you currently using alcohol? Yes ☐No ☐
Reproductive History
- If Male, have you had a vasectomy? Yes ☐No ☐
- If Female, have your started your period? Yes ☐No ☐
Is your cycle regular? Yes ☐No ☐ Explain:
- Have you gone through menopause? Yes ☐No ☐
If yes, last date of period. / Date:
- Have you had a hysterectomy? Yes ☐No ☐
- Have you had a tubal ligation? Yes ☐No ☐
- What method of birth control are you currently using?
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Surgical History- None☐
- List Surgical Procedure
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)Check if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Glaucoma
- Glasses
- Cataracts
- Contact Lenses
- Nearsighted (cannot see far away)
- Farsighted (cannot see close up)
- Trauma
- Astigmatism
- Other
3
Ear, Nose, Throat HistoryCheck if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Sinus Infection-Last
- Nasal Polyps
- Sinus Headache
- Hearing Loss (Diagnosed)
- Deviated Septum
- Ear Infections/ Tubes
- Nasal Congestion
- Recurrent Strep Throat
- Tonsilitis/Pharyngitis
- Other
Endocrine History
Check if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Thyroid Disorder
- Diabetes
- Delayed Growth
- Pancreatitis
- Abnormal Lymph Glands
- Other
4
Genitourinary HistoryCheck if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Prostate Disorder
- Ovarian Cysts
- Menstrual Cramps
- Kidney Stones
- Urinary Tract Infection
- Other
Cardiac History (Heart)
Check if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- High Blood Pressure
- Irregular Heart Beat
- Murmur
- Chest Pain
- Heart Attack
- Blood Clots
- Mitral Valve Prolapse
- Other
5
Pulmonary History (Lungs)Check if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Pneumonia-Last
- Bronchitis-Last
- Emphysema
- Upper Respiratory Infection
- Shortness of Breath
- Croup
- Collapsed Lung
- RSV
- Other
Blood History
Check if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Anemia
- Jaundice
- Abnormal Values (ie: high cholesterol, high liver values)
- Other
6
Skin, Scalp, & Nail HistoryCheck if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Acne
- Hives
- Fungal Infections
- Psoriasis/Eczema
- Breast Mass
- Other
Gastrointestinal History
Check if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Irritable Bowel Syndrome (Diagnosed)
- Crohn’s Disease
- Ulcers
- Hernia-Type:
- Colon Polyps
- Gastric Reflux Disease
- Frequent Heartburn
- Frequent Nausea/Vomiting
- Gallbladder
- Other
7
Neurological HistoryCheck if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Migraine Headaches
- Tension Headaches
- General Headaches
- Depression
- Numbness
- Seizues
- Epilepsy
- Other
Musculoskeletal History
Check if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Diagnosed Arthritis Type:
- Osteoporosis
- Frequent Back Pain
- Frequent Muscle Pain
- Frequent Joint Pain
- Bursitis
- Broken Bone
- Broken Bone
- Broken Bone
- Other
8
Miscellaneous HistoryCheck if Year (Staff only) Changes to original medical history
Experienced began current Change initial/date
Yes No
- Rheumatic Fever
- Measles
- Mumps
- Chicken Pox
- Fifth Disease
- Polio
- Cystic Fibrosis
- Tuberculosis
- Cancer
- Hepatitis Type:
- Abnormal Chest X-Ray
- Other
COMMENTS
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Version 2003 Gen Doc/Revised 11/2009