Comprehensive History Physical Exam Form - Middlesex Hospital

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COMPREHENSIVE HISTORY/PHYSICAL EXAM FORM
PERSONAL DATA
DATE: ______________________
Name:
Date of Birth:
Sex:
M
F
Address:
City:
State:
Zip:
Home phone: ____________
Place of Birth:
Company: _________________________________Position applied for: _______________________
Employed previously by this Co.
Yes
No If Yes, indicate when
___
Whom do we notify in case of an emergency? (Name/Relationship)
Phone #:
Primary Care Physician:
City/State:
Information requested herein will not be used in any manner contrary to any law, rule or regulation and is obtained only for medical
examination to ensure safe job placement in consideration of specific job demands and exposures.
A. MEDICAL HISTORY Have you ever had or have any of the following illnesses? (Yes or No)
Yes
No
Yes
No
Chest Pain / Pressure
Swollen Legs
Heart Disease
Diabetes
High Blood Pressure
Thyroid Problems
Stroke
Arthritis / Rheumatism
Lung Disease/Asthma/Tuberculosis
Glaucoma / Cataracts
Chronic Cough
Hearing Problems/ Perforated Ear Drums
Dizziness / Fainting
Skin Problems
Backache / Pain
Liver Disease
Epilepsy (seizures)
Cancer
Kidney Problems/Blood in Urine
Allergies
Frequent Headache
Anemia
Hernia
Stomach or Bowel Problems including Ulcers
Please explain above Yes responses:____________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Have you ever been treated for…?
Yes
No
Explain for all Yes responses:
Drug Addiction or Alcoholism
Depression
Have you ever smoked?
Do you drink alcoholic beverages?
Have you ever had or been advised to have surgery?
Are you allergic to any medication?
Are you taking any medications presently?
Have you had a recent medical examination?
B. INJURIES
Have you ever experienced:
Yes
No
Yes
No
Upper Extremities (Shoulder/Arm/Wrist/Hand)
Bone Fracture
Injuries
Back Injuries
Lower Extremities (Leg/Knee/Foot) Injuries
Head Injuries
Lost Consciousness
Neck Injuries
Car Accident with Injury
Comments
:______________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Rev. 11/14

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