Health History & Physical Examination Form - Suny Poly Page 2

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PERSONAL MEDICAL HISTORY
Student Completes
Student Name ____________________________________________________
Date __________________
ALLERGIES AND OTHER SEVERE ADVERSE REACTIONS:
Yes
No
Blood Related
 Anemia
 NO KNOWN ALLERGIES
 Blood disorders /Bleeding trait/Sickle Cell
Aspirin
 HIV/AIDS
Insect/bee sting
 Phlebitis
Penicillin
Sulfa
Cardiac
 Dizziness/fainting
 Heart Disease
Latex
Lidocaine/xylocaine
 High blood pressure
 High cholesterol
X-ray contrast
Food
 Rheumatic fever
Gastro-Intestinal
 Chronic inflammatory bowel disease (Crohn’s,
Other (specify)
ulcerative colitis, etc.)
_____________________________________________________________
 Digestive trouble
 Hepatitis
Please describe allergic reaction: __________________________
 Peptic ulcer
_____________________________________________________
Mental Health/Emotional
 ADHD/ADD
Do you use an EpiPen when you have a reaction?  Yes  No
 Alcohol or drug use, problem or treatment
If yes, do you have an EpiPen?  Yes  No
 Anxiety or nervousness
 Autism spectrum disorder (Asperger's, etc.)
 Bipolar disorder/manic depression
CURRENT MEDICATIONS: frequent or regular - Please list
 Depression
 Eating disorders: bulimia/anorexia nervosa
 Acne medication
Bowel medication
 PTSD
_____________________
___________________________
Neurological
 Migraine/recurrent headaches
 Seizure disorder (epilepsy)
 ADHD/ADD medication
 Headache medication
 Head Injury/Concussion
______________________
______________________
Respiratory
 Asthma
 Chronic bronchitis/emphysema
 Allergy medication
 Heart rhythm medication
 Ear infections/hearing problems
______________________
______________________
 Hay Fever
 Pneumonia
 Allergy shots
 Insulin
 Tuberculosis or past positive tuberculin test
______________________
______________________
 Treatment to prevent tuberculosis or for active
tuberculosis
 Anti-depressants
 Over the counter (OTC’s)
Urinary/Reproductive
____________________
______________________
 Breast disease
 Kidney disease (congenital /chronic//other)
 Anxiety medication
 Pain medication
 Menstrual problems
______________________
______________________
 Pregnancy
 Sexually transmitted disease
 Asthma medication
 Seizure medication
 Urinary infection
______________________
______________________
Other
 Absence/damage to any paired organ (kidney,
 Birth control pills
 Thyroid medication
eye, etc.)
______________________
______________________
 Acne (under treatment)
 Arthritis
 Blood pressure medication
Other: (specify) ________
 Cancer or malignancy
______________________
_____________________
 Cerebral palsy
 Chicken pox
FAMILY MEDICAL HISTORY: Check the appropriate box(s), if any,
 Diabetes Mellitus
of the following diseases that apply to your family.
 Fracture/sprains
 Insomnia/sleep problems
Grand-
 Orthopedic problems/injuries
Parent(s)
Parent(s)
Sibling(s)
 Skin disorder
Alcoholism or drug addiction
 Systemic lupus
Bleeding disorders
 Thyroid disorder
Cancer
 Tobacco use
Other: Explain below
Heart disease
If yes to any of the above, explain: ______________________________________
High blood pressure
____________________________________________________________________
Emotional/mental illness
____________________________________________________________________
Stroke
Have you had any surgery? Explain: _______________________________________
Sudden death before 35 years
____________________________________________________________________
Other (please specify)
Have you been hospitalized? ____________________________________________
Other medical concerns (specify)__________________________________________
None of the above
_____________________________________________________________
2

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